Choose a body system (Gastrointestinal System or Urinary System).
Create an example of a brief detailed medical note written in SOAP format for your selected body system.
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Ans) SOAP for Abdominal pain:
Example: 47-year old female presenting with abdominal pain.
Onset: When did the CC begin?
Location: Where is the CC located?
Duration: How long has the CC been going on for?
Characterization: How does the patient describe the CC?
Alleviating and Aggravating factors: What makes the CC better?
Worse?
Radiation: Does the CC move or stay in one location?
Temporal factor: Is the CC worse (or better) at a certain time of
the day?
Severity: Using a scale of 1 to 10, 1 being the least, 10 being the
worst, how does the patient rate the CC?
It is important for clinicians to focus on the quality and clarity
of their patient's notes, rather than include excessive detail.
History
Medical history: Pertinent current or past medical
conditions
Surgical history: Try to include the year of the surgery and
surgeon if possible.
Family history: Include pertinent family history. Avoid documenting
the medical history of every person in the patient's family.
Social History: An acronym that may be used here is HEADSS which
stands for Home and Environment; Education, Employment, Eating;
Activities; Drugs; Sexuality; and Suicide/Depression.
Review of Systems (ROS)
This is a system based list of questions that help uncover symptoms not otherwise mentioned by the patient.
General: Weight loss, decreased appetite
Gastrointestinal: Abdominal pain, hematochezia
Musculoskeletal: Toe pain, decreased right shoulder range of
motion
Current Medications, Allergies
Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often.
Example: Motrin 600 mg orally every 4 to 6 hours for 5
days
Objective
This section documents the objective data from the patient encounter. This includes:
Vital signs
Physical exam findings
Laboratory data
Imaging results
Other diagnostic data
Recognition and review of the documentation of other
clinicians.
A common mistake is distinguishing between symptoms and signs.
Symptoms are the patient's subjective description and should be
documented under the subjective heading, while a sign is an
objective finding related to the associated symptom reported by the
patient. An example of this is a patient stating he has “stomach
pain,” which is a symptom, documented under the subjective heading.
Versus “abdominal tenderness to palpation,” an objective sign
documented under the objective heading.
Assessment
This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. Elements include the following.
Problem
List the problem list in order of importance. A problem is often known as a diagnosis.
Choose a body system (Gastrointestinal System or Urinary System). Create an example of a brief detailed...
Choose a body system (Gastrointestinal System or Urinary System). Create a fictional example of a brief detailed medical note written in SOAP format for your selected body system. S: O: A: P:
Select a body system. (Integumentary, Musculoskeletal, and Nervous Systems) Create an example of a detailed medical note written in SOAP format for your selected body system. S: O: A: P:
The Use of Medical Terminology of the Endocrine, Cardiovascular, and Respiratory Systems in Medical Reports Select a body system (Gastrointestinal System or the Urinary System). Create an example of a brief detailed medical note written in SOAP format for your selected body system. S: O: A: P:
Select a body system. (Integumentary, Musculoskeletal, and Nervous Systems) Create an example of a detailed medical note written in SOAP format for your selected body system.
The Use of Medical Terminology of the Endocrine, Cardiovascular, and Respiratory Systems in Medical Reports Select a body system (Endocrine System, Cardiovascular System or the Respiratory System). Create an example of a brief detailed medical note written in SOAP format for your selected body system. S: O: A: P:
The Use of Medical Terminology of the Endocrine, Cardiovascular, and Respiratory Systems in Medical Reports Select a body system (Endocrine System, Cardiovascular System or the Respiratory System). Create an example of a brief detailed medical note written in SOAP format for your selected body system. S: O: A: P:
The Use of Medical Terminology of the Endocrine, Cardiovascular, and Respiratory Systems in Medical Reports Select a body system (Endocrine System, Cardiovascular System or the Respiratory System). Create an example of a brief detailed medical note written in SOAP format for your selected body system. S: O: A: P:
Part C: The Use of the Medical Terminology of the Integumentary, Musculoskeletal, and Nervous Systems in Medical Reports Select a body system. (Integumentary, Musculoskeletal, and Nervous Systems) Create an example of a detailed medical note written in SOAP format for your selected body system. S: O: A: P:
Write a brief, fictitious medical record using terminology to describe each body system. Utilize the various chart notes at the end of each chapter as examples for that body system. Based upon the patient presentation, write a medical record entry in the following format that includes each body system with more details pertaining to the body system of the patient complaint. Please copy and paste the list below into the answer box and fill in the entry for each area....
Create a map or outline of the nervous system and include the required data: Divisions of the nervous system and function Neurotransmitters of the Sympathetic/Parasympathetic Nervous System Sympathetic Response/Parasympathetic Response Example of Adrenergic Rx & It's therapeutic use Example of Adrenergic Blocker Rx & It's therapeutic use Example of Cholinergic Rx & It's therapeutic use Example of Cholinergic Blocker Rx & therapeutic use NERVOUS SYSTEM Peripheral Nervous System CENTRAL NERVOUS SYSTEM Consists of: Brain and spinal cord All the rest...