T — Temporal S — Severity Students can put this into a few simple sentences and use this as a framework for presenting a patient to an instructor, the class, or a preceptor. Mary is a year old woman with severe stabbing upper right quadrant abdominal pain, lasting hours, radiating to her back, aggravated by lying down.
This is a XX -year-old woman who comes in for evaluation of abdominal pain and cholelithiasis. The patient gives a history of a cervical cone biopsy. Her procedure was complicated and required a concomitant or subsequent laparoscopy.
Postoperatively, she developed right lower quadrant abdominal pain, which has slowly but steadily resolved. This was accompanied by some nausea and vomiting.
The bulk of abdominal pain and vomiting has resolved; however, she has still has a little bit of nausea. She indicates that the nausea is substantially less than it had been.
The patient denies any history of epigastric and right upper quadrant abdominal pain. No history of back pain or right shoulder pain.
She has had no history of jaundice, no history of dark urine or acholic stool.
The patient has no particular fatty food intolerance, and eating does not seem to be associated with an exacerbation of her symptoms. She again insists that her abdominal pain has essentially resolved.
During the course of her evaluation, she has had a CAT scan, which demonstrated the presence of gallstones. This finding corroborates abdominal ultrasounds performed prior, which also demonstrated cholelithiasis.
On examination, the patient is a very thin, somewhat anxious-appearing woman who looks approximately her stated age and does not appear to be in any acute distress.
Examination was limited largely to her abdomen, which was scaphoid, soft, and nontender. The patient has no hepatomegaly, no splenomegaly, and no abdominal masses that are discernible. The patient has no direct tenderness, no guarding, no percussion tenderness, and no rebound tenderness.
She has well-healed surgical scars consistent with laparoscopy. It is our impression that the patient has cholelithiasis, which at present appears to be asymptomatic. We counseled her regarding presently asymptomatic cholelithiasis. We discussed the potential presentations of symptoms related to her gallbladder including those, which may be acute and require management and even a visit to the emergency room or even admission to the hospital.
The patient indicated that she understood all of this. We also explained that at present the consensus is that asymptomatic cholelithiasis does not require a cholecystectomy. It is our impression that she has known cholelithiasis, but her current and recent symptoms are unlikely to be related to her cholelithiasis.
We indicated to her that she did not need to make a specific followup appointment but certainly should call should she develop symptoms.One of the most popular posts on this site regards how to write a SOAP note for a patient. The post describes the basic format and outline of the note and what some basic options are for what exactly to describe in the note.
Writing a SOAP note While documentation is a fundamental component of patient care, it is often a neglected one, with therapists reverting to non-specific, overly brief descriptions that are vague to the point of being meaningless.
*Note other documentation formats used in agency/regional area OTHER: _____ *Note other documentation formats used in agency/regional area TYPE OF NOTE IND INDIVIDUAL SESSION GRP GROUP SESSION FAM FAMILY SESSION COL COLLATERAL SESSION 01/03/ IND: S: “I wanted to talk to my kids about how guilty I feel about my drinking.”.
Note Templates / 7 Nursing Note Templates – Samples, Examples. Specifically, the job of a SOAP note is to: Jot down notes using the patient’s chart. How to Write a Hospice Nursing Visit Note Form. Hospice nursing visit is commonly done for those who are terminally ill.
But that isn’t always the case, as scenarios would always. 16+ Sample SOAP Note Examples – PDF, Word. Nursing Soap Note Example. yunusemremert.com Details.
File Format. DOC; Size: 8 KB Download. The template design can support both paragraph style of writing and also a table format. The template can support information of the name and the details of the patient, the case history of the patient.
From this lesson, you will learn why nurses use SOAP notes to write about patients, as well as what each section of the SOAP notes stand for along.