Post by Admin on May 9, 2014 4:26:52 GMT -5
In following patients, how to write soap note:
( example for nephrology patient)
S: subjectively : any new symptom reported by the patient: patinet reports shortness of breath this morning.
O: objectively: any new sign: will be written like this :
Vitals signs.
Fluind status ( ins and outs): amount of all fluinds input. and all fluind output, and mentions urine out put separetly.
Examination
Labs: mention all related abnormal labs, and abnormal becomming normal today and tell the attending the results comparing it with yesterday ( creatinine today is 3 and yesterday was 4 )
Investigations
Procedures
A: assessment : written like this :
33 yo male patient with history of lymphoma diagnoses on 2009. Admitted with acute kidney injury after chemotherapy most probably tumor lysis syndrome.
DD: tumor lysis/ lymphoma infiltration/ cytotoxic drug causing kidney injury/ prerenal from malignant ascites
P: Plan: you write here every thing you will do ( treatment or investigation) and it's good to write why you need this but not necessarily
Renal US : if lymphoma infiltration, kidney will be enlarged
Urine Na and creatinine
Urine analysis
__________________________________________________________________
In some branches you will have to search for basal level for something : which is the average of his blood level of it over last year.
for example, if the patient if chronic kidney diseae patient came with acute kidney injury so you should mention his basal creatinine level durin writing HPI because this is your target of treatment, he will not get normal levels again.
( example for nephrology patient)
S: subjectively : any new symptom reported by the patient: patinet reports shortness of breath this morning.
O: objectively: any new sign: will be written like this :
Vitals signs.
Fluind status ( ins and outs): amount of all fluinds input. and all fluind output, and mentions urine out put separetly.
Examination
Labs: mention all related abnormal labs, and abnormal becomming normal today and tell the attending the results comparing it with yesterday ( creatinine today is 3 and yesterday was 4 )
Investigations
Procedures
A: assessment : written like this :
33 yo male patient with history of lymphoma diagnoses on 2009. Admitted with acute kidney injury after chemotherapy most probably tumor lysis syndrome.
DD: tumor lysis/ lymphoma infiltration/ cytotoxic drug causing kidney injury/ prerenal from malignant ascites
P: Plan: you write here every thing you will do ( treatment or investigation) and it's good to write why you need this but not necessarily
Renal US : if lymphoma infiltration, kidney will be enlarged
Urine Na and creatinine
Urine analysis
__________________________________________________________________
In some branches you will have to search for basal level for something : which is the average of his blood level of it over last year.
for example, if the patient if chronic kidney diseae patient came with acute kidney injury so you should mention his basal creatinine level durin writing HPI because this is your target of treatment, he will not get normal levels again.