NU552 Unit 2 Documenting Subjective information

NU552 Unit 2 Documenting Subjective information

Student Name

Purdue University Global

NU552 Advanced Health Assessment and Diagnostic Reasoning

Prof. Name:

Date

How to Document Subjective Information, Conduct a Health History Interview, and Write a SOAP Note

Accurate documentation of subjective information is the foundation of a comprehensive health assessment. By collecting a detailed patient history, conducting a structured health interview, completing a thorough Review of Systems (ROS), and organizing findings into a SOAP note, healthcare providers can identify patient concerns, develop appropriate differential diagnoses, and create evidence-based plans of care. A systematic approach not only improves diagnostic accuracy but also promotes patient-centered communication, continuity of care, and clinical decision-making in advanced nursing practice.

Understanding the Purpose of the Subjective Health Assessment

The subjective health assessment involves collecting information that the patient reports about their health, symptoms, lifestyle, and medical history before performing a physical examination. Unlike objective findings, subjective data cannot be directly measured or observed by the clinician. Instead, it is obtained through effective communication and active listening.

A structured interview provides a consistent framework for gathering relevant information while building trust between the healthcare provider and the patient. Using open-ended questions encourages patients to describe their concerns in their own words, while follow-up questions help clarify important details that may influence diagnosis and treatment.

For nursing students completing an advanced health assessment, interviewing a volunteer family member or friend provides an opportunity to practice comprehensive documentation and clinical reasoning using standardized assessment techniques.

Key Point: The subjective assessment establishes the clinical foundation for diagnosis, guides the physical examination, and supports the development of an individualized care plan.

Conducting a Comprehensive Health History Interview

A thorough health history interview should follow a logical sequence to ensure that no essential information is overlooked. Before collecting patient information, document the date of the assessment, identify the source of the information, and indicate whether the patient appears to be a reliable historian.

Healthcare providers should create a comfortable environment, maintain patient privacy, and use therapeutic communication techniques throughout the interview. Establishing rapport often leads to more accurate and complete responses.

Documenting Biographical Information

Biographical information provides valuable demographic and social context that may influence a patient’s health risks, communication needs, and treatment decisions. Record only patient initials to protect confidentiality.

The health history should include:

• Patient initials

• Primary language

• Age and date of birth

• Place of birth

• Gender identity

• Race

• Marital status

• Ethnic or cultural background

• Highest level of education completed

• Occupation or profession

• Type of health insurance (private, commercial, state, or federal)

These details help clinicians recognize cultural considerations, socioeconomic influences, and potential barriers to healthcare access while supporting individualized care planning.

Documenting the Chief Complaint (CC)

The Chief Complaint (CC) is the patient’s primary reason for seeking medical care. Whenever possible, document the complaint using the patient’s exact words to preserve accuracy and reduce interpretation bias.

A well-written chief complaint should briefly identify:

• The primary symptom or concern

• When the problem began

• The reason the patient is seeking care today

For example:

“I’ve had chest pain for the past two hours.”

Using the patient’s own language improves communication among healthcare professionals and provides a clear starting point for further assessment.

Clinical Insight: A concise, patient-centered chief complaint guides the History of Present Illness and focuses subsequent clinical evaluation.

Writing the History of Present Illness (HPI)

The History of Present Illness (HPI) provides a chronological narrative describing the patient’s current health concern from the onset of symptoms to the present encounter. An effective HPI captures symptom progression, associated factors, previous interventions, and the impact of the illness on daily functioning.

One of the most widely accepted methods for organizing the HPI is the OLD CARTS framework.

Using the OLD CARTS Framework

In addition to these elements, patients should be asked about their perception of the illness by using questions such as:

“What do you think is causing this problem?”

Understanding the patient’s perspective provides valuable insight into health beliefs, expectations, and concerns that may influence treatment adherence and shared decision-making.

Rather than documenting each OLD CARTS component separately, synthesize the information into a clear narrative paragraph that tells the story of the patient’s illness in chronological order.

Clinical Insight: A complete HPI improves diagnostic accuracy by identifying symptom patterns, risk factors, and the overall impact of the condition on the patient’s quality of life.

Recording the Past Medical History (PMH)

A comprehensive Past Medical History (PMH) identifies previous illnesses, surgeries, treatments, and preventive healthcare measures that may contribute to the patient’s current condition. Reviewing past medical events helps clinicians recognize chronic diseases, recurring health problems, and potential risk factors.

Include information related to:

• Chronic and acute medical conditions

• Childhood illnesses such as measles, mumps, rubella, varicella, pertussis, and streptococcal infections

• Previous surgeries and dates performed

• Hospital admissions

• Blood transfusions

• Obstetric and gynecological history, when appropriate

• Immunization status

• Psychiatric history

• Medication allergies and associated reactions

• Current prescription medications

• Over-the-counter medications

• Vitamins, herbal products, and dietary supplements

• Preventive health screenings and routine examinations

Preventive screening history may include physical examinations, vision and dental evaluations, hearing assessments, electrocardiograms (ECGs), chest radiographs, cervical cancer screening, mammography, lipid testing, colorectal cancer screening, prostate examinations, prostate-specific antigen (PSA) testing, urinalysis, and tuberculosis screening.

Documenting preventive care provides insight into the patient’s long-term health maintenance and identifies opportunities for preventive interventions.

Documenting the Family History (FHx)

A detailed Family History (FHx) helps identify hereditary conditions, familial disease patterns, and genetic predispositions that may increase the patient’s risk of developing certain illnesses.

Assess the health status of immediate and extended family members, including parents, grandparents, siblings, spouse, and children.

For each family member, document:

• Current age or age at death

• Living or deceased status

• Major chronic illnesses

• Genetic disorders

• Communicable diseases

• Significant causes of death, when applicable

Recognizing inherited conditions such as hypertension, diabetes mellitus, cardiovascular disease, cancer, and autoimmune disorders allows clinicians to recommend appropriate screening and preventive strategies.

Key Point: Family history is an essential component of risk assessment and supports early identification of hereditary health conditions.

Assessing Lifestyle and Health Patterns

Lifestyle behaviors, environmental exposures, and psychosocial factors significantly influence overall health and disease progression. A comprehensive assessment extends beyond physical symptoms to evaluate the patient’s daily routines, personal habits, and social circumstances.

Areas commonly explored include:

• Immigration and travel history

• Religious, spiritual, and cultural beliefs

• Personal perception of health

• Nutritional habits and fluid intake

• Bowel and bladder function

• Home environment and living arrangements

• Occupational history and workplace exposures

• Activities of Daily Living (ADLs)

• Instrumental Activities of Daily Living (IADLs)

• Family relationships and support systems

• Cognitive functioning

• Sleep quality and duration

• Exercise habits and physical activity

• Recreational interests

• Tobacco use

• Alcohol consumption

• Recreational or illicit drug use

• Sexual and reproductive health

• Screening for intimate partner violence

• Stress levels and coping strategies

Evaluating these factors helps identify social determinants of health, behavioral risks, and psychosocial influences that may affect treatment outcomes. Incorporating lifestyle information into the health assessment supports holistic, patient-centered care and facilitates individualized health promotion strategies.

Key Clinical Insights

• Subjective assessment provides the foundation for clinical reasoning and guides the physical examination.

• A structured health history improves documentation accuracy and reduces the likelihood of missing clinically significant information.

• Using the OLD CARTS framework ensures a comprehensive evaluation of the patient’s presenting complaint.

• Past medical, family, and lifestyle histories help identify risk factors that influence diagnosis, treatment planning, and preventive care.

• Effective therapeutic communication encourages patient engagement and improves the quality of subjective data collected.

Performing a Comprehensive Review of Systems (ROS)

The Review of Systems (ROS) is a structured, head-to-toe assessment that identifies symptoms the patient has experienced across all major body systems. Unlike the physical examination, the ROS is based entirely on the patient’s self-reported information. It complements the History of Present Illness (HPI) by uncovering additional symptoms that may not have been discussed during the chief complaint.

A thorough ROS helps healthcare providers recognize comorbid conditions, identify previously unreported health concerns, and develop accurate differential diagnoses. Document both pertinent positives (symptoms the patient reports) and pertinent negatives (important symptoms the patient denies) to provide a complete clinical picture.

Clinical Insight: A systematic Review of Systems improves diagnostic accuracy by identifying symptoms that may affect multiple organ systems and influence clinical decision-making.

Assessing General Health

Begin the ROS by evaluating the patient’s overall health status. General symptoms often provide valuable clues about underlying systemic conditions.

Assess for:

• Recent weight gain or weight loss

• Fever or chills

• Fatigue

• Generalized weakness

• Night sweats

Example of a Pertinent Negative

Denies fever, fatigue, weakness, night sweats, or recent weight changes.

Example of a Pertinent Positive

Reports an unintentional 10-pound weight gain over the past two months accompanied by persistent fatigue but denies fever or chills.

Evaluating the Skin, Hair, and Nails

Skin findings frequently reflect both localized dermatologic disorders and systemic diseases. Obtain information about recent or chronic skin changes.

Assess for:

• Rashes

• Lesions

• Itching (pruritus)

• Dryness

• Changes in skin color

• Hair loss or texture changes

• Nail abnormalities

Document the onset, duration, location, severity, and progression of any skin symptoms.

Assessing the Head

Evaluate symptoms related to the head and neurological function.

Assess for:

• Headaches

• Head injuries

• Dizziness

• Vertigo

• Loss of consciousness

Clarify the frequency, duration, severity, and any associated neurological symptoms when abnormalities are reported.

Assessing the Eyes

Visual symptoms may indicate ophthalmic disorders or systemic diseases such as diabetes and hypertension.

Assess for:

• Vision changes

• Blurred or double vision (diplopia)

• Eye pain

• Redness

• Swelling

• Excessive tearing

• Scotomas (visual field defects)

• Use of corrective lenses

• Date of the last eye examination

Include any history of glaucoma, cataracts, or previous eye surgery when applicable.

Assessing the Ears

A comprehensive ear assessment evaluates hearing function and identifies conditions affecting balance or auditory health.

Assess for:

• Hearing loss

• Ear pain

• Tinnitus

• Ear infections

• Ear drainage

• Use of hearing aids

Document whether symptoms affect one or both ears and whether hearing impairment interferes with daily activities.

Assessing the Nose and Sinuses

Nasal and sinus symptoms often contribute to respiratory complaints or allergic conditions.

Assess for:

• Nasal congestion

• Allergies

• Nosebleeds (epistaxis)

• Sinus pressure or pain

• Nasal discharge

• Changes in the sense of smell

Record the duration of symptoms and any seasonal or environmental triggers.

Assessing the Mouth and Throat

Oral health significantly influences nutrition, communication, and overall well-being.

Assess for:

• Dental problems

• Bleeding gums

• Mouth ulcers

• Dry mouth

• Hoarseness

• Sore throat

• Denture use

• Date of the last dental examination

Poor oral health may increase the risk of systemic diseases, making this assessment particularly important.

Assessing the Neck

Neck symptoms may indicate musculoskeletal, endocrine, infectious, or lymphatic disorders.

Assess for:

• Neck pain

• Stiffness

• Swollen lymph nodes

• Thyroid enlargement (goiter)

• Limited range of motion

Document associated neurological symptoms when present.

Assessing the Breasts

Breast assessment should include routine screening practices and any current concerns.

Assess for:

• Breast pain

• Lumps

• Nipple discharge

• Skin changes

• Previous breast disease

• Self-breast examination practices

• Mammography history

• Axillary tenderness or swelling

When appropriate, include gender-specific recommendations based on current screening guidelines.

Assessing the Respiratory System

Respiratory symptoms provide important information about pulmonary function and underlying cardiopulmonary disease.

Assess for:

• Cough

• Sputum production

• Hemoptysis

• Shortness of breath (dyspnea)

• Wheezing

• Chest discomfort associated with breathing

• Previous lung disease

• Occupational or environmental exposures

• Tuberculosis testing

• Previous chest imaging

Characterize cough by onset, duration, sputum color, and aggravating factors.

Assessing the Cardiovascular System

Cardiovascular assessment identifies symptoms associated with heart disease and circulatory disorders.

Assess for:

• Chest pain

• Palpitations

• Orthopnea

• Peripheral edema

• Cyanosis

• Hypertension

• Coronary artery disease

• Heart murmurs

Clarify the characteristics of chest pain using the OLD CARTS framework whenever cardiac symptoms are reported.

Assessing the Gastrointestinal System

A gastrointestinal assessment evaluates digestive function and identifies symptoms affecting nutritional status.

Assess for:

• Appetite changes

• Difficulty swallowing (dysphagia)

• Heartburn

• Nausea

• Vomiting

• Abdominal pain

• Constipation

• Diarrhea

• Rectal bleeding

• Food intolerances

Include bowel habits, stool characteristics, and recent gastrointestinal procedures when appropriate.

Assessing the Genitourinary System

The genitourinary assessment identifies urinary and reproductive health concerns.

Assess for:

• Urinary frequency

• Painful urination (dysuria)

• Blood in the urine (hematuria)

• Urgency

• Nocturia

• Urinary incontinence

When appropriate, obtain a gender-specific reproductive history, including menstrual history, pregnancy history, contraceptive use, menopause status, or prostate-related symptoms.

Assessing the Peripheral Vascular System

Peripheral vascular symptoms may indicate circulatory disorders affecting the extremities.

Assess for:

• Claudication

• Cold hands or feet

• Varicose veins

• Blood clots

• Numbness

• Non-healing ulcers

• Swelling of the extremities

These findings help identify peripheral arterial or venous disease.

Assessing the Musculoskeletal System

Evaluate the patient’s mobility and musculoskeletal function.

Assess for:

• Joint pain

• Muscle pain

• Muscle cramps

• Arthritis

• Gout

• Reduced range of motion

• Joint swelling

Document whether symptoms interfere with work, exercise, or activities of daily living.

Assessing the Neurological System

Neurological symptoms help identify disorders involving the brain, spinal cord, or peripheral nerves.

Assess for:

• Syncope

• Seizures

• Weakness

• Tremors

• Stroke history

• Memory loss

• Coordination problems

• Mood or behavioral changes

Assess symptom onset, progression, and associated neurological deficits when abnormalities are reported.

Assessing the Hematologic System

Hematologic assessment evaluates blood disorders and immune-related conditions.

Assess for:

• Anemia

• Easy bruising

• Excessive bleeding

• Blood transfusions

• Enlarged lymph nodes

• Exposure to toxic substances

Document any history of clotting disorders or hematologic malignancies.

Assessing the Endocrine System

Endocrine disorders often present with generalized symptoms affecting multiple body systems.

Assess for:

• Heat intolerance

• Cold intolerance

• Excessive sweating

• Polyuria

• Polydipsia

• Polyphagia

• Diabetes mellitus

• Thyroid disorders

• Hormone replacement therapy

These symptoms may indicate metabolic or hormonal abnormalities requiring further evaluation.

Assessing the Psychiatric System

Mental health is an essential component of a comprehensive health assessment.

Assess for:

• Anxiety

• Depression

• Mood disorders

• Memory impairment

• Previous psychiatric diagnoses

• Hospitalizations for mental illness

• Suicide attempts or suicidal ideation

Evaluate how emotional or psychological symptoms affect daily functioning, interpersonal relationships, and quality of life.

Clinical Insight: Screening for mental health concerns during the health history promotes early identification, timely intervention, and holistic patient care.

Organizing the Clinical Assessment

After completing the subjective interview and physical examination, synthesize the collected information into a clinical assessment. This step involves analyzing the patient’s history, reported symptoms, examination findings, and available diagnostic evidence to determine the most likely diagnosis.

The assessment should include:

• Primary diagnosis: The condition that best explains the patient’s presentation.

• Differential diagnoses: Other potential conditions with similar clinical features.

• Rule-in diagnoses: Conditions supported by the available evidence.

• Rule-out diagnoses: Conditions that require additional testing before being excluded.

Every diagnosis should be supported by objective evidence and clinical reasoning rather than assumptions. Organizing diagnoses in this manner improves diagnostic accuracy and supports evidence-based decision-making.

Developing an Evidence-Based Plan of Care

The Plan section of a SOAP note outlines the interventions required to address the patient’s health concerns. Every recommendation should directly relate to the assessment findings and promote patient-centered care.

An effective plan of care typically includes:

• Recommended laboratory studies and diagnostic imaging

• Medication initiation, adjustment, or continuation

• Patient education regarding the diagnosis and treatment

• Lifestyle modifications to reduce risk factors

• Preventive health recommendations

• Follow-up appointments

• Referrals to specialists or interdisciplinary healthcare providers when indicated

A well-developed plan promotes continuity of care, improves patient outcomes, and ensures that treatment decisions are supported by current clinical evidence.

Example SOAP Note

The following example demonstrates how subjective and objective findings can be organized into the SOAP (Subjective, Objective, Assessment, and Plan) format. Using a standardized SOAP note improves clinical communication, supports continuity of care, and provides a clear rationale for diagnosis and treatment planning.

Subjective

Chief Complaint (CC)

“I have had an itchy, scaly rash on my scalp and knees for about two weeks. The rash has spread to my face, and I avoid going outside because I feel people are staring at me. I have also been having trouble sleeping, eating, and concentrating.”

History of Present Illness (HPI)

A 30-year-old White female presents with a two-week history of an intensely pruritic, erythematous, scaly rash involving the scalp and both knees. She reports experiencing similar episodes in the past; however, previous flare-ups were less severe and did not affect the scalp. Since the onset of her current symptoms, she has experienced persistent itching that interferes with sleep and daily activities. The visible lesions have also caused emotional distress, decreased appetite, impaired concentration, and social withdrawal. She denies exposure to new soaps, detergents, medications, or known allergens.

Past Medical History

The patient’s medical history includes:

• Hypertension

• Allergic rhinitis

• Total hysterectomy performed for uterine fibroids

Current Medications

• Lisinopril 20 mg orally once daily

• Loratadine 10 mg orally once daily

Allergies

No known drug allergies (NKDA).

Family History

• Mother: Hypertension

• Brother: Hypertension

• No known family history of autoimmune skin disorders.

Social History

The patient lives with her spouse and two children and is employed as a bank teller. She denies tobacco use, alcohol consumption, recreational drug use, or any history of physical, emotional, or sexual abuse.

Review of Systems

Skin: Reports thick, scaly plaques involving the scalp and bilateral knees with persistent itching. Denies changes in hair growth, nail abnormalities, or suspicious skin lesions.

Psychiatric: Reports poor sleep, decreased appetite, reduced concentration, embarrassment related to the rash, and social isolation. Denies suicidal or homicidal ideation.

Objective

General Appearance

Alert, cooperative, and oriented to person, place, time, and situation. The patient appears well-groomed and in no acute distress.

Vital Signs

• Blood Pressure: 128/72 mmHg

• Heart Rate: 70 beats/minute

• Respiratory Rate: 18 breaths/minute

• Temperature: 98.7°F (37.1°C)

• Height: 5 ft 7 in

• Weight: 168 lb

• Body Mass Index (BMI): 26.3 kg/m²

Physical Examination

Skin

Warm and dry with well-demarcated erythematous plaques covered by silvery scales on the bilateral knees and frontal scalp. No evidence of secondary infection or drainage.

HEENT

Pale, boggy nasal mucosa with mild postnasal drainage. Oral mucosa is moist without lesions.

Respiratory

Breath sounds are clear bilaterally with mild end-expiratory wheezing. Respirations are even and unlabored.

Cardiovascular

Regular heart rate and rhythm without murmurs, gallops, or rubs. Peripheral pulses are palpable and symmetrical.

Neurological

Alert and oriented ×4. Cranial nerves II–XII are intact. Motor strength and sensation are within normal limits.

Assessment

Based on the patient’s history and physical examination, the most likely diagnosis is plaque psoriasis, supported by recurrent erythematous plaques with characteristic silvery scales involving the scalp and extensor surfaces.

Primary Diagnosis

Plaque Psoriasis

Supporting Findings

• Recurrent scaly plaques

• Bilateral knee involvement

• Scalp lesions

• Persistent pruritus

• Previous similar episodes

• Absence of infectious findings

Differential Diagnoses

• Seborrheic dermatitis

• Atopic dermatitis (eczema)

• Tinea corporis

• Contact dermatitis

• Cutaneous lupus erythematosus

Associated Conditions

• Adjustment disorder with depressed mood related to chronic dermatologic disease

• Allergic rhinitis

• Essential hypertension

Clinical Insight: Developing differential diagnoses ensures that alternative conditions are considered before confirming the final diagnosis, reducing the risk of diagnostic error.

Plan

Diagnostic Evaluation

Recommended diagnostic studies include:

• Complete Blood Count (CBC)

• Erythrocyte Sedimentation Rate (ESR)

• C-Reactive Protein (CRP)

• Vitamin D level

• Skin biopsy if the diagnosis remains uncertain following clinical evaluation

Pharmacologic Management

Initiate evidence-based treatment consisting of:

• High-potency topical corticosteroid (e.g., clobetasol)

• Vitamin D analogue (e.g., calcipotriol)

• Daily emollient therapy to improve skin hydration

• Hydroxyzine for pruritus and sleep disturbance when clinically appropriate

• Continue antihistamine therapy and intranasal corticosteroid for allergic rhinitis

Patient Education

Educate the patient regarding:

• The chronic and relapsing nature of psoriasis

• Medication adherence

• Proper application of topical medications

• Daily skin moisturization

• Trigger avoidance, including excessive stress, skin trauma, and smoking

• Recognition of symptoms requiring prompt medical attention

Lifestyle Recommendations

Encourage lifestyle modifications that support symptom control and overall health, including:

• Stress management techniques

• Adequate sleep

• Balanced nutrition

• Regular physical activity

• Gentle skincare practices

• Avoidance of harsh soaps and skin irritants

Follow-Up

Schedule a follow-up appointment within 2 to 4 weeks to evaluate treatment response and symptom improvement. Referral to a dermatologist should be considered if lesions worsen, fail to respond to topical therapy, or if systemic treatment becomes necessary.

Key Takeaways

Accurate subjective documentation forms the basis of advanced health assessment and clinical decision-making. A comprehensive patient interview, detailed health history, systematic Review of Systems, and well-structured SOAP note enable healthcare providers to identify health concerns, prioritize physical examination findings, develop evidence-based differential diagnoses, and create individualized treatment plans.

Using structured assessment tools such as the OLD CARTS framework promotes consistency in documentation while improving communication among healthcare professionals. Comprehensive SOAP notes also enhance continuity of care by ensuring that patient information is organized, clinically relevant, and easily accessible throughout the healthcare continuum.

Quick Clinical Facts

What is the purpose of a subjective health assessment?

A subjective health assessment gathers information directly from the patient regarding symptoms, medical history, medications, lifestyle, and health concerns. This information guides physical examination, clinical reasoning, and treatment planning.

Why is the OLD CARTS framework important?

OLD CARTS provides a structured method for evaluating symptoms by assessing onset, location, duration, characteristics, aggravating or alleviating factors, radiation, timing, and severity. It improves documentation accuracy and supports differential diagnosis.

Why is the Review of Systems (ROS) necessary?

A comprehensive ROS identifies symptoms affecting multiple body systems, uncovers previously unreported health issues, and strengthens diagnostic accuracy by supporting comprehensive clinical assessment.

What are the four components of a SOAP note?

SOAP documentation consists of:

• Subjective findings

• Objective findings

• Assessment

• Plan

This standardized format promotes effective communication among healthcare professionals and supports continuity of patient care.

Frequently Asked Questions

What is the difference between subjective and objective data?

Subjective data consists of information reported directly by the patient, including symptoms, medical history, lifestyle habits, and personal concerns. Objective data includes measurable findings obtained through physical examination, diagnostic testing, and clinical observation.

How does the OLD CARTS mnemonic improve patient assessment?

OLD CARTS ensures clinicians collect complete information about a patient’s symptoms in a consistent manner. By evaluating symptom onset, location, duration, characteristics, aggravating or relieving factors, radiation, timing, and severity, healthcare providers can develop more accurate diagnoses and treatment plans.

Why is documenting family history important?

Family history helps identify inherited conditions and genetic risk factors such as hypertension, diabetes, cardiovascular disease, autoimmune disorders, and certain cancers. This information supports preventive screening and individualized patient care.

What should be included in a comprehensive Review of Systems?

A complete ROS should assess every major body system, including general health, skin, HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurological, endocrine, hematologic, peripheral vascular, and psychiatric systems while documenting both pertinent positives and pertinent negatives.

Why are differential diagnoses included in the assessment?

Differential diagnoses allow clinicians to compare multiple possible conditions before confirming the final diagnosis. This systematic approach minimizes diagnostic errors and ensures appropriate testing and evidence-based management.

How does a SOAP note improve patient care?

SOAP notes organize clinical information into a standardized format that improves communication among healthcare professionals, supports evidence-based decision-making, facilitates continuity of care, and provides a clear record of patient assessment and treatment.

Conclusion

Comprehensive subjective documentation is a critical component of advanced nursing practice. Collecting an accurate health history, performing a systematic Review of Systems, documenting findings using the SOAP format, and applying structured assessment tools such as OLD CARTS strengthen clinical reasoning and support evidence-based care. Consistent documentation practices improve diagnostic accuracy, enhance interdisciplinary communication, and contribute to safer, patient-centered healthcare across diverse clinical settings.

References

American Academy of Dermatology Association. (2024). Psoriasis: Diagnosis and treatment. https://www.aad.org/public/diseases/psoriasis

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). https://www.psychiatry.org/psychiatrists/practice/dsm

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier. https://www.us.elsevierhealth.com/

NU552 Unit 2 Documenting Subjective information

Bickley, L. S. (2025). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer. https://shop.lww.com/

Jarvis, C. (2024). Physical examination and health assessment (10th ed.). Elsevier. https://evolve.elsevier.com/