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Post by Dr. Carol on Aug 14, 2015 16:30:25 GMT
1. Define and describe each of the following. What should be included in each section? a. Subjective b. Objective c. Assessment d. Plan Patient soap sample.docx (13.14 KB) Read the attached SOAP note. In your post, answer the following: 2. There are 3 errors in the SOAP where things are not in the correct place. What are the errors, and where should they appear in the SOAP? 3. Is there anything in the SOAP note that is inappropriate, and should not be included? 4. Let’s say that you wrote this SOAP, and then realized that the Temperature was actually 101.2. How would you correct this? |
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Post by melissa edwards on Aug 14, 2015 19:14:13 GMT
A) Subjective means what the patient actually tells you what the problem is or felling. Things to include is this section are past medical history, chief complaint, you asking the patient when did the problem start, how long has it be going on, anything make it worst or better, ect.
B) Objective means gathering information from doing vital signs, exam, or what other the test they might do.
C) Assessment means what the physician founds out from the testing on the patient and make the diagnosis,and any long term goals
D) Plan means that it is what the doctor comes out on how to treat the condition and decide what to do to make it go away. Example:medication,therapy
2) vital signs,and they should be put in the objective. no PMH reported and no family history reported should actually be in the Subjective column.
3) Yes, the part where they say he is a 35 year old male and is wealthy and hamdsome
4) I would correct this by putting one line through the temperature and putting in the correct temp, then date and initial it to show i made a correction.
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Post by Caitlin on Aug 17, 2015 17:12:35 GMT
S- In this section you should have what the patient came in for, there complaints and any extra information that pertains to the complaint that the patient may state. O- This section should have the observation from the doctor as far as the exam they preform and any other information that they notice that may pertain to the complaint IE: x-rays or labs ordered A- For the assessment part of the notes this is where you would put the diagnosis for the patient P- In the plan portion of the notes is where the follow would be placed along with medications, also if there is any at home care suggested
- The medication should be listed in the plan, The patients vitals should be listed in the "O" section of the notes, and the patient stating he has not had any falls or headaches should be in the "O" section - The statement that he is very handsome should not be in the SOAP notes - If I noticed the error I would go back in and cross out the temp that I had put in, write the date and my initial's along with correct temp. |
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Post by Sarah Lee on Aug 20, 2015 22:24:21 GMT
S-The reason why the patient came in for a visit
O-What observation's the doctor made and what labs the doctor ordered
A-The patient's diagnoses
P-What the plan is for the patient such as medications and limitations
2)The medications should be in the plan section
2)The vital signs should be in the objective section
2)The past medical and family history should be in the subjective section
3) The patient is wealthy and handsome
4)You draw a straight line through the error and initial above it and date it
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Post by Cierra Banks on Aug 20, 2015 22:38:21 GMT
Subjective- information gathered from the patient, usually a chief complaint. This section includes, vital signs, any past medical history, family medical history, how they are feeling, and how long they been experiencing their health problems.
Objective- information gathered during the visit, which include vital signs, examinations, X-rays, and testing.
Assestment- the physician's preliminary diagnosis and prognosis/goals of the patient.
Plan- indicates the section of the chart discussing the plan of care for the patient, how to treat the patients health condition, and when to return for a follow up appointment if necessary.
2.) The vital signs should be taken out of the subjective section and put in the objective section, the prescription prescribed should be in the plan section instead of the assesment, and the "PMHx reported" and the "no family hx reported" should be in the subjective section.
3.) The part where it states " Pt is a handsome and wealthy 35 year old man" is highly inappropriate and should not be included.
4.) I would correct it by drawing a line through the incorrect temperature, put the correct temperature, write the date, and sign my initials.
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Post by Kimbleda on Aug 20, 2015 23:19:23 GMT
1)A)Subject is for reason patient believe that they are seeing the physician for.
B)Objective is for data gathered during the during the visit
C)Assessment is for the physician preliminary diagnosis and prognosis
D)Plan is for discussing the plan of care for this patient.
2)the vital signs should be place in the objective section, the no family past medical history should be place in the subjective section, and the medications should be place in the plan section.
3)Yes!, the part where they include that the patient is an handsome and wealthy 35 years old man.
4) the way I would correct it is by drawing a line through the error and write the correct information above it initial and date it .
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bethk
New Member
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Post by bethk on Aug 21, 2015 1:34:45 GMT
S- This stands for the subjective items that are taken from the patient. This is where you write down what the patient believes that they are visiting the doctor for and list any PMH in this area.
O- This is where the objective and observed information goes. The vital signs of the patient are put in this area, any past exam or testing findings are listed in this area. In this are is also where you put anything that you have observed about the patient such as brusing.
A- This is where the physician list the assessment of the patient. His/her diagnosis will be found in this area.
P- This is where the plan of care is going to be listed for the patient. The follow up visit and any RXs that are given will be listed in this area.
In the example of the SOAP notes the three things that were put in the wrong area are 1) No family history should have been put in the "S" (subjective) part of the notes. The vital signs that were put in the subjective area should have been put in the objective part. The RX that was given to the patient should have been listed in the "P" area of the SOAP notes. The error that was made while writing down the patients temp. is corrected by making one line through it, writing the correct temp. and then putting your initials beside it to identify that you are the one that made the correction.
In the Subjective area when it listed that the patient was a 35 year old, wealthy, handsome man should not have been put in there. Yes we do need to know the patients age but him being wealthy and handsome has nothing to do with how the patient will be treated. Our opinions of any patient have no place in any records that are kept.
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Post by Takeeda Hale on Aug 21, 2015 15:36:47 GMT
1. A) Subjective: information gathered from the patient the things they patient believes they are seeing a physician for,usually the chief complaint
B) Objective: the data gathered durning the visit such as vital signs ,examination and testing findings
C) Assessment: The physicians preliminary diagnosis and prognosis/goals
D) Plan: Plan of care
Things that were wrong: medication should have been in the plan section,the vital signs should have been in the objective section,the past medical and family history should have been in the subjective section. The patient is wealthy and handsome is inappropriate, and the error draw a line through it initial and date above it.
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