SOAP notes activity - Sandra Hightower Class Info



Student HandoutSOAP NotesGoal: To understand the basic concept of a SOAP note in theory and practice.Objective: Student will identify SOAP note abbreviations with accuracy.IntroductionThe SOAP note is an acronym for subjective, objective, assessment, and plan. The SOAP note is a method of documentation used by healthcare providers to write out notes in a patient’s chart, along with other common formats, such as the admission note.Documenting patient encounters in the medical record is an integral part of the practice workflow starting with patient appointment scheduling, communication between and among providers, and to “write out notes”, including medical billing and coding. Although there are other systems that can be used, the SOAP is considered an industry standard.During the course of a patient’s care, the patient is initially assessed, reassessed constantly, and finally assessed upon discharge from the physician’s care. Each of these types of assessments results in a type of SOAP note. An initial note is written after the initial patient assessment. An interim, or progress, note is written periodically, reporting the results of reassessment. A discharge note is written at the time that therapy is discontinued.Writing in a Medical RecordAccuracy: Never falsely, exaggerate, or makeup data. SOAP notes are part of a permanent, legal document. Incorrect spelling, grammar, and punctuation can be misleading. Objective information should be stated in a factual manner. “Information” should always be objective.Brevity: Information should be stated concisely. Use short succinct sentences. Avoid long winded statements. Abbreviations can help with brevity. Abbreviations used should be from the accepted list of the facility at which you practice. Brevity can also be overdone. Enough information must be present to get ideas across.Correcting Errors: “White out” (correction fluid) should not be used on a medical record. Trying to destroy or attempting to obliterate information makes it look as if the health professional is trying to “cover up” malpractice. The proper method of correcting a mistake make in charting is to put a line through the error, write “error” above the mistake, date it, and initial it.Signing Your Notes: You should sign every entry that you make into the medical record. All notes should be signed with your legal signature. No nicknames should be used.Let’s try an example:Patient is a 2-day-old male who comes in with his mother for his first visit after birth. He was a full-term infant, vaginally delivered. Mother provides prenatal history, family history including the paternal Rh factor and information regarding inherited red cell defects. The mother says the he has been “very fussy” lately. The baby weighed 5 lb. 7 ounces. His temperature was 98.6 degrees. His skin was yellowish in coloration, including sclera. The physician conducted tests which included direct and indirect bilirubin levels. Further tests revealed gram-negative bacterial infection and serum bilirubin levels at 7mg/dl. The physician did blood tests for both the mother and the infant for blood group incompatibilities, hemoglobin levels, the direct Coombs’ test, and hematocrit. After reviewing the data, the physician felt that the patient has hyperbilirubinemia which was due to gram-negative bacterial infection. The physician administered an injection of albumin (1g/kg of 25% salt-poor albumin), antibiotics given for the infection and the physician also asked that the mother bring the infant in three days so that he could monitor the progress.In the case study above, there is a great deal of information. Let’s rewrite the information in the form of a SOAP note.The Heald Clinic1234 Vancouver Street, Portland, Oregon 97218 * 503-233-6758Patient:Blade ConnorsAccount:CONNBL002Date:11/08/yyyyAttending Physician: D. Van White, MDSubjective (S): Pt is a 2-day-old who comes in for his first office visit after birth. He was a full-term infant, vaginally delivered. Mother provides prenatal history, family history including the paternal Rh factor and information regarding inherited red cell defects. The mother reports that the infant is “very fussy”.Objective (O): Wt. 5 lb. 7 ounces, T 98.6. Skin has yellowish skin coloration, including sclera. Tests, including direct and indirect bilirubin levels, reveal gram-negative bacterial infection and serum bilirubin levels at 7 mg/dl. Blood tests are also performed to test infant and mother both for blood group incompatibilities, hemoglobin level, direct Coombs’ test, and hematocrit.Assessment (A): Hyperbilirubinemia, due to gram-negative bacterial infectionPlan (P):1. Rx albumin administration (1 g/kg of 25% salt-poor albumin)2. Rx antibiotics for infection3. Follow-up appointment in three daysD. Van White, MDVW/mtD: 11/08/yyyy 09:50:16T: 11/09/yyyy 12:55:01(VW stands for the physician, mt, is the person that typed the report, D: is the date of dictation and the T: is the date it was transcribed, yyyy stand for the current year.)Please answer the following questions:What does the SOAP acronym stand for? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Why are SOAP notes important?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SOAP notes/Chart notes are a legal document ___yes ___noIt is fine to use liquid correction fluid as long as the physician says it’s okay. ___yes ___noWhen writing a SOAP note, it’s fine to write long exhaustive notes as long as you include all relevant information. ___yes ___noAny abbreviations used anywhere can be used in your SOAP notes ___yes ___no. If no, please explain your answer.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Common Abbreviations ExerciseUsing your Medical Terminology Textbook (Appendix B), please identify the following abbreviations:AB, Ab, ab ____________________ac ____________________Adm ________________________alt hor_________________Alt noct _____________________amt___________________AODM ______________________c_____________________Ca__________________________CA, ca_________________Cap, caps____________________CBR___________________BIL, Bil, Bili ___________________Bx, bx__________________CIS_________________________COL___________________COPD_______________________Dg, dg, dx_______________DOB________________________dsg____________________DOA________________________DOC___________________EN, endo____________________FTND___________________Gtt_________________________h_______________________HBP________________________gm_____________________FHT________________________GB_____________________HEM_______________________HPN____________________Isol_________________________OB_____________________OD_________________________od_____________________TID, tid, t.i.d.__________________U/A, UA_________________Q__________________________qd, q.d._________________Qh, q.h._____________________q 2 h____________________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download