Using either or both chapters (6 and/or 7) create a SOAP note using five medical words discussed in this week’s reading.
We have no idea what words are in these two chapters. We also don't know what SOAP is.
write a thorough three paragraph medical terminology paper
To create a SOAP note using five medical words discussed in this week's reading, let's first understand what a SOAP note is. A SOAP note is a type of documentation used by healthcare providers to record patient information and progress during a medical encounter. It stands for Subjective, Objective, Assessment, and Plan. The subjective section includes patient-reported information, the objective section includes measurable data observed by the healthcare provider, the assessment section includes the healthcare provider's diagnosis or evaluation, and the plan section outlines the treatment or management plan for the patient.
For this exercise, we'll refer to Chapters 6 and 7 to choose the five medical words to include in the SOAP note.
1. Subjective - The subjective section is where we document patient-reported information. Let's choose the word "pain" from Chapter 6, as it is a common complaint in medical encounters.
Example: The patient reports experiencing mild lower back pain for the past week.
2. Objective - The objective section includes measurable data observed by the healthcare provider. Let's choose the word "vital signs" from Chapter 7, as it is a standard objective measurement in medical encounters.
Example: Vital signs taken include a blood pressure of 120/80 mmHg, heart rate of 80 beats per minute, and temperature of 98.6°F.
3. Assessment - The assessment section includes the healthcare provider's diagnosis or evaluation. Let's choose the word "diabetes" from Chapter 6, as it is a common chronic condition.
Example: The assessment indicates that the patient has type 2 diabetes based on their medical history and elevated blood glucose levels.
4. Plan - The plan section outlines the treatment or management plan for the patient. Let's choose the word "medication" from Chapter 7, as it is often part of the treatment plan.
Example: The plan includes prescribing metformin 500mg twice daily to help regulate blood sugar levels.
5. Additional word - Lastly, let's choose one more word from either chapter to add to the SOAP note. For variety, let's choose "infection" from Chapter 6, as it is a common concern in healthcare settings.
Example: Assessment also considers the possibility of an infection at the surgical site and recommends monitoring for signs of redness, swelling, or discharge.
Combining these words, we can create a SOAP note:
Subjective: The patient reports experiencing mild lower back pain for the past week.
Objective: Vital signs taken include a blood pressure of 120/80 mmHg, heart rate of 80 beats per minute, and temperature of 98.6°F.
Assessment: The assessment indicates that the patient has type 2 diabetes based on their medical history and elevated blood glucose levels.
Plan: The plan includes prescribing metformin 500mg twice daily to help regulate blood sugar levels.
Additional: Assessment also considers the possibility of an infection at the surgical site and recommends monitoring for signs of redness, swelling, or discharge.
Remember, the choice of medical words may vary based on the specific content of the chapters you are referring to.