NR 509 Advanced Health Assessment: Tina Jones
Comprehensive SOAP Note
NR 509: Shadow Health Comprehensive Assessment SOAP Note
Patient Information
• Name: Not Disclosed (Shadow Health Standardized Patient)
• Age: 28 years
• Gender: Female
• Ethnicity: Caucasian
• Date of Visit: [Insert Date]
• Preceptor: [Insert Name]
• Student: [Your Name]
Subjective Data
Chief Complaint (CC):
“I’m here for my annual physical exam.”
History of Present Illness (HPI):
The patient presents for a comprehensive health assessment as part of an
annual physical exam. She reports generally good health with no acute
concerns. Denies fever, chills, chest pain, shortness of breath, abdominal
pain, or urinary symptoms. She exercises 3–4 times per week and eats a
balanced diet. Reports occasional tension headaches relieved by rest and
hydration. No recent hospitalizations or ER visits.
, Past Medical History (PMH):
• Asthma diagnosed in childhood, currently well controlled with
albuterol inhaler PRN.
• No history of hypertension, diabetes, or heart disease.
• Immunizations are up to date.
Past Surgical History (PSH):
• Tonsillectomy at age 8.
• No other surgeries reported.
Medications:
• Albuterol HFA inhaler: 2 puffs PRN for wheezing.
• Multivitamin, daily.
Allergies:
• Penicillin: Causes rash.
• No known food or environmental allergies.
Family History:
• Father: Hypertension, age 58.
• Mother: Hypothyroidism, age 56.
• Maternal grandmother: Breast cancer (diagnosed at 62).
• No family history of diabetes, stroke, or heart attack.
Social History:
Comprehensive SOAP Note
NR 509: Shadow Health Comprehensive Assessment SOAP Note
Patient Information
• Name: Not Disclosed (Shadow Health Standardized Patient)
• Age: 28 years
• Gender: Female
• Ethnicity: Caucasian
• Date of Visit: [Insert Date]
• Preceptor: [Insert Name]
• Student: [Your Name]
Subjective Data
Chief Complaint (CC):
“I’m here for my annual physical exam.”
History of Present Illness (HPI):
The patient presents for a comprehensive health assessment as part of an
annual physical exam. She reports generally good health with no acute
concerns. Denies fever, chills, chest pain, shortness of breath, abdominal
pain, or urinary symptoms. She exercises 3–4 times per week and eats a
balanced diet. Reports occasional tension headaches relieved by rest and
hydration. No recent hospitalizations or ER visits.
, Past Medical History (PMH):
• Asthma diagnosed in childhood, currently well controlled with
albuterol inhaler PRN.
• No history of hypertension, diabetes, or heart disease.
• Immunizations are up to date.
Past Surgical History (PSH):
• Tonsillectomy at age 8.
• No other surgeries reported.
Medications:
• Albuterol HFA inhaler: 2 puffs PRN for wheezing.
• Multivitamin, daily.
Allergies:
• Penicillin: Causes rash.
• No known food or environmental allergies.
Family History:
• Father: Hypertension, age 58.
• Mother: Hypothyroidism, age 56.
• Maternal grandmother: Breast cancer (diagnosed at 62).
• No family history of diabetes, stroke, or heart attack.
Social History:
