Unit 3: Introduction to Physical Exam, General Survey, Vital Signs, Skin, and HEENT
SOAP Note Section II: Lifestyle Pattern and ROS
This section of the SOAP note will include history of lifestyle patterns and the review of systems (ROS).
Document appropriate data in the relevant body system.
Do not state “Negative, NA or Unremarkable” for any systems because the reader will not know which questions were actually asked by the provider.
This is a comprehensive health history and should not contain physical exam findings. The focused history data is relevant to the chief complaint and identified by pertinent positive data documented during the health history.
Address each component of the SOAP note as noted in the written guide with relevant data.
You may continue with the same volunteer to complete each section of the SOAP note.
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