Microbiota and What the Clinical Gastroenterologist Needs ...
PROGRESS NOTE (SOAP Notes) H.A.Soleimani MD Gastroenterologist.
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Transcript of PROGRESS NOTE (SOAP Notes) H.A.Soleimani MD Gastroenterologist.
PROGRESS NOTE (SOAP Notes (
The medical student should be the person most intimately aware of the patient's status, it is appropriate that he or she be given the responsibility of writing the note each day.
PROGRESS NOTE (SOAP Notes (
One of the most important documents in the medical record is the daily progress note
PROGRESS NOTE (SOAP Notes (
The progress noteThe progress noteReflect whatReflect what transpired transpired during the during the previous 24previous 24 hourshoursUpdates a patient's clinical course each day
Summarizes the ward team's ongoing assessment and plan.
PROGRESS NOTE (SOAP Notes (
Progressnote Progressnote include a include a directed directed or or focal focal examination, and examination, and plansplans for for further further evaluationevaluation..
Use the SOAP formatUse the SOAP format
Subjective
Objective
Assessment
Plan
S=SubjectiveS=Subjective
O=ObjectiveO=Objective
A=AssessmentA=Assessment
P=PlanP=Plan
Progress note
Uses:
1,Daily evaluation of a hospitalized patient
2,Return visit in outpatient clinic
Progress note
Subjective (Focused history)
1. Information you have learned from the patient or people caring for the patient
SUBJECTIVE SUMMARY
The note begins with a statement of the patient's own (subjective) assessment of his condition.
SUBJECTIVE SUMMARY
The subjective portion should include some of the patient’s or parents' own words.
OBJECTIVE SUMMARY
1 -Vital signs
2-The patient's general appearance
3-Physical exam findings
4- Any diagnostic test results (Laboratory and imaging..)
OBJECTIVE SUMMARY
VITAL SIGNS
Blood Presure
Pulse Rate
Respiration Rate
Temperature
(Weight, Pain, xygen xygen SaturationSaturation? )
OBJECTIVE SUMMARY
PHYSICAL FINDINGS: An directed physical examination should be recorded with all pertinent areas described.
OBJECTIVE SUMMARY
Laboratory data: Although one will often wish to mention certain laboratory data in the assessment, there is no need to list all of the results.
PROGRESS NOTE (SOAP Notes (
Because the progress note is focused on "progress,' the assessment and plan section includes only problems that are being addressed during the hospitalization.
ASSESSMENT
AssessmentAssessment::Provide Provide your your working working diagnosisdiagnosis and and mention the mention the statestate of of the the patientpatient
ASSESSMENT
Identify the major or primary assessment supported by the patient database and any other associated assessments.
ASSESSMENT
1.What do you feel is the patient’s differential diagnosis and why?
2.Organized by problem or organ system
PLAN
Each plan should be divided into 1.Diagnostics(Lab .x.ray..)
2.Therapeutic
3.Patient Education
4.Health Promotion
Strategies
PLANPLAN
For each problem what diagnostic testing will you order?
How will you treat each problem or
diseases?
PROGRESS NOTE (SOAP Notes (
Progress note maybe quite brief. It does not need to be crafted in fall sentences as long as it is easily comprehensible.
PROGRESS NOTE (SOAP Notes (
It is also important to remember that the progress note, like the oral and written presentations, is part of the student's education and should be reviewed with the intern, resident, or attending.
PROGRESS NOTE (SOAP Notes (
The date, time, title, are essential UUSE SE BLACK INKBLACK INK
SIGN SIGN AND AND writewrite YOUR NAME YOUR NAME on any chart notes
PROGRESS NOTE (SOAP Notes
Mr. Hamedi is an 84 year old man who comes to the hospital 7 day ago for angiography and today he have worsening leg swelling. The swelling started 3 days ago in his ankles and has progressively moved toward his groin.
PROGRESS NOTE (SOAP Notes
He also feels short of breath. For the past two days he can’t walk without resting halfway. He has difficulty breathing when lying in bed.
PROGRESS NOTE (SOAP Notes)
1. Vital signs: BP 120/72, HR 68,
RR 20, T 36
2. Chest: crackles 1/3 up bilaterally.
PROGRESS NOTE (SOAP Notes)
Extremities: No erythema or tenderness.
2+ pitting edema bilaterally to his knees.
PROGRESS NOTE (SOAP Notes)
3.Cardiac: Regular rate and rhythm, normal S1 and S2, S3 is present, No murmur
PROGRESS NOTE (SOAP Notes)
Abdomen: Normoactive bowel sounds,
soft, non-tender, non-distended, no hepatomegaly or splenomegaly
PROGRESS NOTE (SOAP Notes)
Labs visit: Sodium 125 (135 -145)
Potassium 3.6 (3.5 – 5.1)
BUN 40 (10 – 20)
Creatinine1.5 (0.6 – 1.3)
PROGRESS NOTE (SOAP Notes)
Shortness of Breath
New dyspnea on exertion
S3 crackles and edema
1.Congestive heart failure or new anginaor new anginaASSESSMENT
Problem
PROGRESS NOTE (SOAP Notes)
EdemaProblem
ASSESSMENT
1.Congestive heart failure or new anginaor new angina
2.Nephrotic syndrome
3.hypothyroidism
PROGRESS NOTE (SOAP Notes)
No suggestion of
pure pulmonary disease
No suggestion of Hypertension –Blood presure is well controlled and is probably not contributing to his
presenting complaints.
Congestive heart failure or new or new anginaangina
We will order an EKG right now to assess cardiac rhythm and acute injury.
Congestive heart failure or new or new anginaangina
We will also send him for an echocardiogram to measure his cardiac function.