posted a soap, teacher asked that i change the s & o. this is what i did:
s - patient is here for a non routine checkup, she is 4 months pregnant and is complaining of weakness, fatigue, lack of appetite and lightheadedness.
o - HEENT: normal. patient has lost 5 lbs. fromlast weeks appointment, looks tired, is more pale than usual, and apperars to have labored breathing. patient admits to having a family history of anemia and gestational diabetes mellitus. after performing a ferritin test, including CBC (complete blood count), a blood smear and glucose test, results show erythrocytes are abnormally large and immature. vitamin b12 and sugar levels are normal.
What is "a soap"?
If a tutor reads this who understands the specialized vocabulary, how will he/she know if these are OK if he/she hasn't read your original?
SOAP are the notes witten in patients charts
yes
To change the S (Subjective) and O (Objective) sections of the SOAP note, you can follow these steps:
Subjective (S):
1. Begin by including relevant personal information about the patient, such as their name, age, and reason for the visit.
2. State the reason for the visit in a clear and concise manner. In this case, the patient is a 4-month pregnant woman who is complaining of various symptoms.
3. Include the specific symptoms she is experiencing, which are weakness, fatigue, lack of appetite, and lightheadedness.
4. Mention any pertinent medical history, including her family history of anemia and gestational diabetes mellitus.
Objective (O):
1. Start by documenting the initial examination findings related to the patient's general appearance and vital signs.
2. In this case, mention that the patient looks tired, is more pale than usual, appears to have labored breathing, and admits to having lost 5 lbs. since her last appointment.
3. Include the specific examination findings, especially those related to the affected systems or areas. In this example, describe the results of the ferritin test, CBC, blood smear, and glucose test.
4. Specifically, mention that the patient's erythrocytes (red blood cells) are abnormally large and immature, while vitamin B12 and sugar levels are normal.
With these changes, the revised S and O sections would look as follows:
S (Revised):
The patient is a 4-month pregnant woman presenting today for a non-routine checkup. She complains of weakness, fatigue, lack of appetite, and lightheadedness. She also mentions having a family history of anemia and gestational diabetes mellitus.
O (Revised):
Upon examination, the patient appears tired and more pale than usual. She has lost 5 lbs. since her last appointment. Her breathing appears labored. Test results show abnormally large and immature erythrocytes. Vitamin B12 and sugar levels are normal.
Remember, the SOAP note is a method for healthcare professionals to document patient encounters. It is crucial to present objective information accurately and provide relevant subjective details.