S.O.A.P Note

S.O.A.PNote

S.O.A.PNote

Part I:

Complete thefollowing chart typing information that should be included in theS.O.A.P format (for example, 1. Weight 160 pounds is objectiveinformation)

Subjective

Objective

Assessment

Plan

  1. Amoxicillin 500mg to take twice a day for two weeks

  1. Weight 160 pounds

Examination by Physician

Return in two weeks for follow-up

  1. A complaint of a sore throat for one week.

  1. Blood Pressure 118/80

Patient Reported Nausea for two days

  1. A wound on left arm

  1. Pulse 78

  1. Patient Denied Vomiting and Diarrhea

  1. Respiration 19

  1. Height 5’3

  1. Temperature 103

Part II:

Answer thefollowing questions:

  1. What is a chief complaint?

Chief complaint is aprecise statement that is used in medical history taking to describesymptom or diagnosis recommended by a physician.

  1. What is the purpose of a progress note?

Used to give adetailed documentation of patient’s clinical progress and status

Allow for comparisonof past and present status of patients

It is a legalmedical document

It is important inbilling

Communicates anyfindings in the course of treatment between the physicians and theother interested parties

  1. What part of a S.O.A.P note can a medical assistant document in?

Medical assistantcan document on the S-part and O-part only, that is, subjectiveobservations and objective observations (Sleszynski, Glonek &ampKuchera, 1999).

  1. Why is documentation important in a health care environment?

Proper documentationis essential for provision of quality healthcare and medicalservices. Through the documentation, a patient would know when tovisit the labs, surgeries and any other treatments (Sleszynski,Glonek &amp Kuchera, 1999). Generally, full information about thepatient is acquired.

  1. Write a sample chief complaint in the chart below

A 50 year oldfemale her reason for visit is “Snoring” that makes it difficultfor her to sleep

References

Sleszynski, S. L., Glonek, T., &amp Kuchera, W. A. (1999).Standardized medical record: a new outpatient osteopathic SOAP noteform: validation of a standardized office form against physician`sprogress notes. JAOA: Journal of the American OsteopathicAssociation, 99(10), 516-516.

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