Assignment: Journal Entries, SOAP
Assignment: Journal Entries, SOAP
In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing SOAP Notes.
Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
- Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Almost without exception, some medical history about the patient is available at the time of the physical examination. Rarely, there may be no history, or at best brief recordings of acute events. Information pertinent to the physical examination can be learned from observation of speech, gestures, habits, gait, and manipulation of features and extremities. Interactions with relatives and staff are often revealing. Pigmentary changes such as cyanosis, jaundice, and pallor may be noted. Diaphoresis, blanching, and flushing may provide clues about vasomotor tone related to mood or physiologic abnormalities. Aspects of patient habits, interests, and relationships can be ascertained from pictures, books, magazines, and personal objects at the bedside.
The Physician–Patient Interaction
Aside from the hospital room and office, physical examination may occur in a variety of other settings where it is difficult to establish privacy and quiet. The best resource available to the physician to set the stage for the physical examination is to communicate respect and a genuine interest in the patient’s welfare. The patient should be addressed politely and asked to perform the required maneuvers of the examination, a technique far preferable to imperative language such as, “I want you to. …” Patients should be prepared for unpleasant portions of the examination.
Aside from explanations and reassurance, it is not necessary to maintain a continuous conversation with the patient during the examination. Avoid embarrassing the patient. Be certain that draping material is used appropriately and that personal areas are not subjected to undue exposure. An examination that ends abruptly may diminish the value of the doctor–patient relationship and may destroy its therapeutic content. The patient may benefit from a brief summary of relevant findings and may require reassurance about what has and has not been found.