In week 2 we learnt about taking a patient’s health history and how this helps our assessment of the patient. We also practiced the methods of assessing the musculoskeletal and cardiovascular systems.

Health history is important as it provides us with information that we may not have known. This can include hospitalizations, surgeries, accidents and traumas. Part of health history is also personal habits, medications and family history. Acquiring some understanding of the patient’s everyday life provides insight into what could make their symptoms better or worse. Obtaining the patient’s family history allows us to keep an eye out for possible illnesses that could be genetically inherited.

Part of our labs included learning how to document our findings. The SOAP acronym is what we will be using.

• Subjective data: what the patient tells us; to be recorded in quotes.
• Objective data: observations and measurements, eg. vital signs, clinical assessments.
• Assessment/Analysis: what we think the problem is after interpreting the data
• Plan: what to do next; plan and re-evaluate.