Which information would the nurse include in the assessment category when using SOAP to documents in the medical record?
1. The client's blood pressure was 177/93.
2. The recent loss of employment and insurance has prevented the client from being able to afford prescription medications.
3. The client reports having lost her job and insurance 3 months ago.
4. Referrals have been made to social services to determine financial assistance programs available.
Correct Answer: 2
The "A" component of the SOAP note refers to conclusions drawn from the subjective and objective data obtained. The client's recent loss of employment and the potential that this was a contributing factor in the inability to afford medications is an example of a conclusion. The client's reported blood pressure would be an example of objective data. Objective data is information that can be measured by the examiner. Blood pressure is not an example of subjective information nor is it a conclusion. The client's reported loss of employment and insurance is an example of subjective data. The statement does not include conclusions as to the results of these events. Making referrals to social services is an example of an intervention. It is not a conclusion.
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