Question

76. Ashlynn hears an employee speaking on the intercom to a patient. How should she handle this situation? To whom, if anyone should Ashlynn report this activity and why? What problems might be caused if this type of conversation is overheard? 77 Ashlynn answers the phone; the caller is a male pharmaceutical representative who has been visiting the clinic for several months. She cheerfully greets him and asks if he is calling to make an appointment. He states that he wants to make an appointment with Ashlynn - for a date. How should he handle this call? What problems could arise if this were a patient and Ashlynn were to accept the date?

Answer 1

Organization of SOAPE notes:

S: S stands for subjective data, i.e., chief complaint and related details as described by the patient. The subjective description is not always given by the patient, can also be given by family members, caregivers, or significant others. The patient encounter reasons are usually given in lay terminology without giving emphasis on medical terms. This portion includes symptoms, medications used, allergies etc. This is prone to misunderstanding and misinterpretation if the person voicing it does give importance to clarity. The important subheadings that come under this heading are:

• Chief complaint (CC): Includes presenting problem.
• History of present illness (HPI): Includes patient's age, sex, and reason for visit. This describes onset, location, duration characterization, alleviating and aggravating factors, radiation of pain, worse or better at a certain time of day i.e., the temporal factor, and severity that is about pain on a scale of 1 to 10 etc.
• Past medical history (PMH): Includes past medical conditions.
• Past surgical history (PSH): Includes past surgeries of the patient with date etc.
• Family history (FH): Includes pertinent disease conditions of close relatives of the patient.
• Social history (SH): Includes home environment, education, employment, food habits, activities, positive or negative drug, nicotine, and alcohol abuse, sexuality, mental status etc.
• Review of systems (ROS): Includes the details of system-wise symptoms as mentioned by the patient. General, gastrointestinal, musculoskeletal, integumentary etc., are some of them.
• Current medications: Give details of the medications taken by the patient at present.
• Allergies: Gives details of allergies to any medication.

O: O stands for objective data, i.e., any observations or factual measurements made by the physician or nurse. This includes:

• Vital signs: This includes patient's pulse, temperature, blood pressure, respiratory rate, and weight measured on arrival.
• Physical exam findings: Includes the findings made by the physician or nurse like scattered rales, skin color, necrosis, erythema, pallor, tenderness etc., that they come across during the examination. This is mostly a finding related to the patient's symptoms.
• Laboratory data: Lab values on admission, which include any value related to patient's symptoms.
• Imaging and other diagnostic data: This includes scan, X-rays, nuclear medicine studies etc.
• Review of other clinicians' reports: Past reports of the patient by other clinicians are reviewed.

A: A stands of assessment, it is the potential diagnosis arrived by the clinician based on the subjective and objective data. Important elements of assessment include:

• Problem: Includes the list of problems or diagnoses in the order of importance.
• Differential diagnosis: Includes the list of possible diagnoses.

P: P stands for plan of care. The plan provided by the clinician based on the diagnoses. The physician directs how to manage a problem.

E: E stands for evaluation, it is the assessment of treatment outcome.