LEARNING OBJECTIVE: Recall proper patient care reporting and assessment procedures.

Although physicians determine the overall medical management of a person requiring healthcare services, they depend upon the assistance of other members of the healthcare team when implementing and evaluating that patientís ongoing treatment. Nurses and medical technicians spend more time with hospitalized patients than all other providers. This situation places them in a key position as data-collecting and -reporting resource persons.

The systematic gathering of information is called data collection and is an essential aspect in assessing an individualís health status, identifying existing problems, and developing a combined plan of action to assist the patient in his health needs. The initial assessment is usually accomplished by establishing a health history. Included in this history are elements such as previous and current health problems; patterns of daily living activities, medication, and dietary requirements; and other relevant occupational, social, and psychological data. Additionally, both subjective and objective observations are included in the initial assessment gathering interview and throughout the course of hospitalization.


Accurate and intelligent assessments are the basis of good patient care and are essential elements for providing a total healthcare service. You must know what to watch for and what to expect. It is important to be able to recognize even the slightest change in a patientís condition, since such changes indicate a definite improvement or deterioration. You must be able to recognize the desired effects of medication and treatments, as well as any undesirable reactions to them. Both of these factors may influence the physicianís decision to continue, modify, or discontinue parts or all of the treatment plan.

Oral and Written Reporting

Equally as important as assessments is the reporting of data and observations to the appropriate team members. Reporting consists of both oral and written communications and, to be effective, must be done accurately, completely, and in a timely manner. Written reporting, commonly called recording, is documented in a patientís clinical record. Maintaining an accurate, descriptive clinical record serves a dual purpose: It provides a written report of the information gathered about the patient, and it serves as a means of communication to everyone involved in the patientís care. The clinical record also serves as a valuable source of information for developing a variety of care-planning activities. Additionally, the clinical record is a legal document and is admissible as evidence in a court of law in claims of negligence and malpractice. Finally, these records serve as an important source of material that can be used for educating and training healthcare personnel and for conducting research and compiling statistical data.

Basic Guidelines for Written Entries

It is imperative that you follow some basic guidelines when you make written entries in the clinical record. All entries must be recorded accurately and truthfully. Omitting an entry is as harmful as making an incorrect recording. Each entry should be concise and brief; therefore, avoid extra words and vague notations. Recordings must be legible. If an error is made, it must be deleted following the standard policy for correcting erroneous written notations. Finally, your entries in the clinical record must include the time and date, your signature, and your rate or rank.

SOAP Note Format

SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT, and PLAN. Medical documentation of patient complaint(s) and treatment must be consistent, concise, and comprehensive.

SUBJECTIVE.óThe initial portion of the SOAP note format consists of subjective observations. These are symptoms verbally given to you by the patient orby a significant other (family or friend). These subjective observations include the patientís descriptions of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness.

OBJECTIVE.óThe next part of the format is the objective observation. These objective observations include symptoms that you can actually see, hear, touch, feel, or smell. Included in objective observations are measurements such as temperature, pulse, respiration, skin color, swelling, and the results of tests.

ASSESSMENT.óAssessment follows the objective observations. Assessment is the diagnosis of the patientís condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

PLAN.óThe last part of the SOAP note is the plan. The plan may include laboratory and/or radiologic tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., binnacle list, Sick-in-Quarters (SIQ), admission to hospital), patient directions, and follow-up directions for the patient.


Table 2-1 outlines the self-questioning techniques for patient assessment and reporting is a good guide toassist you in developing proficiency in assessing and reporting patient conditions.


Table 21.óSelf-Questioning Techniques for Patient Assessment and ReportingĺContinued

Area of Concern  Assessment Criteria
General Appearance Is the patient
  • of average build, short, tall, thin, or obese?
  • well-groomed?
  • apparently in pain?
  • walking with limp, wearing a cast, walking on crutches, or wearing a prosthetic extremity?
Behavior Does the patient
  • appear worried, nervous, excited, depressed, angry, disoriented, confused, or unconscious?
  • refuse to talk?
  • communicate thoughts in a logical order or erratically?
  • lisp, stutter, or have slurred speech?
  • appear sullen, bored, aggressive, friendly, or cooperative?
  • sleep well or arouse early?
  • sleep poorly, moan, talk, or cry out when sleeping?
  • join ward activities?
  • react well toward other patients, staff, and visitors?
Position Does the patient
  • remain in one position in bed?
  • have difficulty breathing while in any position?
  • use just one pillow or require more pillows to sleep well?
  • move about in bed without difficulty?
Skin Is the patientís skin
  • flushed, pale, cyanotic (bluish hue), hot, moist, clammy, cool, or dry?
  • bruised, scarred, lacerated, scratched, or showing a rash, lumps, or ulcerations?
  • showing signs of pressure, redness, mottling, edema, or pitting edema?
  • appearing shiny or stretched?
  • perspiring profusely?
  • infested with lice?
Eyes Are the patientís
  • eyelids swollen, bruised, discolored, or dropping?
  • sclera (whites of eyes) clear, dull, yellow, or bloodshot?
  • pupils constricted or dilated, equal in size, react equally to light?
  • eyes tearing or showing signs of inflammation or discharge?
  • complaints about pain; burning; itching; sensitivity to light; or blurred, double, or lack of vision?
Ears Does the patient
  • hear well bilaterally?
  • hold or pull on his ears?
  • complain of a buzzing or ringing sound?
  • have a discharge or wax accumulation?
  • complain of pain?
Nose Is the patientís
  • nose bruised, bleeding, or difficult to breathe through?
  • nose excessively dry or dripping?

Are the patient's nares (nasal openings) equal in size?

Is the patient sniffling excessively?

Mouth Does the patientís
  • mouth appear excessively dry?
  • breath smell sweet, sour, or of alcohol?
  • tongue appear dry, moist, clean, coated, cracked, red, or swollen?
  • gums appear inflamed, ulcerated, swollen, or discolored?
  • teeth appear white, discolored, broken, or absent?

Does the patient

  •  wear dentures, braces, or partial plates?
  • complain of mouth pain or ulcerations?
  • complain of an unpleasant taste?
Chest Does the patient
  • have shortness of breath, wheezing, gasping, or noisy respirations? cough?
  • have a dry, moist, hacking, productive, deep, or persistent cough?
  • have white, yellow, rusty, or bloody sputum?
    • Is it thin and watery or thick and purulent (containing pus)?
    • How much is produced?
    • Does it have an odor?
  • complain of chest pain?
    • Where is the pain?
    • Is the pain a dull ache, sharp, crushing, or radiating?
    • Is the pain relieved by resting?
    • Is the patient using medication to control the pain (i.e., nitroglycerin)?
Abdomen Does the patient
  • Have an abdomen that looks or feels distended, boardlike, or soft?
  • have a distended abdomen, and, if so, is the abdomen distended above or below the umbilicus or over the entire abdomen?
  • belch excessively?
  • feel nauseated, or has he vomited?
    • If so, how often, and when?
    • What is the volume, consistency, and odor of the vomitus?
    • Is it coffee ground, bilious (containing bile), or bloody in appearance?
    • Is patient vomiting with projectile force?
Bladder & Bowel Does the patient have
  • bladder and bowel control?
  • normal urination volume and frequency?
    • Does the urine have an odor?
    • Is the urine dark amber or bloody?
    • Is the urine cloudy; does it have sediment in it?
    • Is there pain, burning, or difficulty when voiding?
  • diarrhea, soft stools, or constipation?
    • What is the color of the stool?
    • Does the stool contain blood, pus, fat, or worms?
    • Does the patient have hemorrhoids, fistulas, or rectal pain?
Vagina or Penis Does the patient have
  • ulcerations or irritations?
  • a discharge or foul odor?
    • If there is a discharge present, is it bloody, purulent, mucoid (containing mucous), or watery?
    • What is the amount?
  • associated pain?
    • If pain is present, where is it located?
    • Is it constant or intermittent?
    • Is it tingling, dull, aching, burning, gnawing, cramping, or crushing?
Food & Fluid Intake Does the patient
  • have a good, fair, or poor appetite?
  • get thirsty often?
  • have any kind of food intolerance?
Medications Does the patient
  • take any medications? (If so: what, why, and when last taken?)
  • have medications with him?
  • have any history of medication reactions or allergies?



A patient will often require inpatient care, whether due to injury or illness. Frequently, the inpatient will need specialized treatments, perhaps even surgery. In this part of the chapter, we will discuss the procedures for assisting both the medical inpatient and the surgical inpatient.