Soap Note



Soap Note

Introduction

The term soap note is defined as a particular format to record the information of the patient regarding the procedures of treatment. In the late 1960's the simple yet a comprehensive technique, usually developed for the mental and medical providers of health care. In order to organize the treatment plan, symptoms, assessment and observations the SOAP notes are organized. For an effective process of treatment it is very essential to document the treatment .In every employment settings some form of documentation is required and the most famous format in a medical setting is the Soap note. Among all disciplines of medical the eventual goal of the system was to advance and progress and communication for caring of the patients.

Benefits of Soap noting

The Soap notes offer unlimited benefits to a nurse,

It assists to develop strategies and to identify obstacles to help the client tin order to achieve his goal.

It also provides the technique for tracking to compile the information that is applicable to use so that the negative and positive behavioural patterns of the client can be recognized.

It also helps to offer the existing evidences of the progress that an individual can shows the clients, after reviewing and using the notes with them usually demonstrate professionalism and builds credibility and trust that aids in enhancing the preservation and client compliance.

It usually consists of the four parts: Subjective, objective, Assessment and Plan. This information is presented in the following way.

Subjective Data

General Patient Information

Date of Interview: 2nd July 2012 Time: 1500 Client:  20 y.o. White American female.

Source and Reliability: patient, 100% reliable and credible Primary Language: English.                              Secondary Language: None                          Chief Complaint (CC): For 12 days history of nasal congestion, and purulent nasal drainage.

History of Present Illness (HPI)

Patient said she was completely working fine until 2 weeks ago she started to experience facial pressure, Myalgia and fever.Her eyes turned watery and when she rubbed it got red and worse. She was otherwise normal and healthy. After Six days of illness her problem started to improve. But in the last few days it got worse, she tried OTC and “Tylenol allergy”, that relieved her symptoms but she suffered from persisting nasal congestion. When she came in the hospital her right cheek was hurting a lot, the pain was very severe, the over counter medicines no longer helped. She felt congested, at any time of the day the symptoms were not worse or at any particular location. The right facial cheeks of the pateint hurt when she opens her mouth or speaks. The patient also had an upper respiratory tract infection when she was admitted.The patient denies the discharge of eyes with pus.

Past Medical History

General state of health: patient always complains about her allergy issues.

Past Illnesses: The patient experienced preceding cold consistently, Arthritis in both knee joints and she denied any cardiovascular disorders and chronic disease.

Injuries: None.

Hospitalizations: On 02/04/2005 had a car accident she experienced nasal bone fx. According to her the frequency of her nasal discharge increase as a result ...