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screening for colorectal cancer and
prostate cancer.

VI. Documenting Health and Physical Assessment Findings

A. Documentation of findings may be either written or recorded
electronically (depending on agency protocol).
B. Whether written or electronic, the documentation is a legal
document and a permanent record of the client’s health status.
C. Principles of documentation need to be followed and data need to
be recorded accurately, concisely, completely, legibly, and
objectively without bias or opinions; always follow agency
protocol for documentation.
D. Documentation findings serve as a source of client information
for other health care providers; procedures for maintaining
confidentiality are always followed.
E. Record findings about the client’s health history and physical
examination as soon as possible after completion of the health
assessment.
F. Refer to Chapter 6 for additional information about
documentation guidelines.

Box 12-1
Types of Health and Physical Assessments

Complete Assessment: Includes a complete health history and physical
examination and forms a baseline database.
Focused Assessment: Focuses on a limited or short-term problem, such as the
client’s complaint.
Episodic/Follow-up Assessment: Focuses on evaluating a client’s progress.
Emergency Assessment: Involves the rapid collection of data, often during the
provision of lifesaving measures.

Table 12-1

SOAP Notes

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