Physical Assessment


Documentation of problem based assessment of the neurological system.


Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings.


Course Competency:

Apply assessment techniques for the neurological and respiratory systems.




Content: Use of three sections:

· Subjective

· Objective

· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.



· Standard American English (correct grammar, punctuation, etc.)



Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from