NURSING ANM AND GNM

Detailed explanation-1: -A common mistake is distinguishing between symptoms and signs. Symptoms are the patient’s subjective description and should be documented under the subjective heading, while a sign is an objective finding related to the associated symptom reported by the patient.

Detailed explanation-2: -SOAP is an acronym for: Subjective-What the patient says about the problem / intervention. Objective-The therapists objective observations and treatment interventions.

Detailed explanation-3: -S-Subjective The S section is the place to report anything the client says or feels that is relevant to their session or case. This includes any report of limitations, concerns, and problems. Often living situations and personal history (ex. PMH or Occupational Profile) are also included in the S section.

Detailed explanation-4: -The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient’s current presentation, such as: Vital signs are often already included in the chart. However, it is an important component of the SOAP note as well. Vital signs and measurements, such as weight.