SOAP Note And eMedley Entries Essay

Week 8 project 3 SOAP Note and eMedley Entries Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template. The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE. Submission Details: By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided. Name your SOAP note document SU_NSG6440_W8_SOAPLastName_FirstInitial.doc. Include the reference number from CORE in your document. Submit your document to the Submissions Area by the due date assigned.SOAP Note And eMedley Entries Essay

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You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.SOAP Note and eMedley Entrie

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.SOAP Note And eMedley Entries Essay

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.SOAP Note And eMedley Entries Essay

A SOAP note is a document usually used in the medical fraternity to capture a patient’s details in the process of treatment. This is one of the many formats that are used by professionals in the health sector. The SOAP note is usually included in the patient’s medical record for the purpose of informing any other health officer that will handle the patient, to act as evidence that the patient has been clinically assessed and to provide the clinical reasoning behind the same.SOAP Note And eMedley Entries Essay

SOAP stands for the following:

S – Subjective

O – Objective

A – Assessment

P – Plans

Let’s look at these in details.

Subjective
This is what the patient explains, basically where the problem is and is usually in form of narration.

Objective
This is what the health officers make use of the patient’s narration that is an objective observation of the patient’s problem. In this case, the health officer needs to put down all the information and aspects that should be looked out for.

Assessment
Here the health officer looks at the various concerns of the patient. Apart from that, it includes the professional opinion of the therapists based on the subjective and objective findings.

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Plans
These are the measures to be taken or the treatment needed to achieve the objectives.SOAP Note And eMedley Entries Essay
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Before proceeding, let’s have a brief look at the history of the SOAP notes.
The practice of preparing SOAP notes began in the 1960s. This was developed by Dr. Lawrence Weed a member of the University of Vermont. The purpose of the SOAP notes was to help in the problem-oriented medical record.

Now you are asking yourself, why we need SOAP notes.

Every medical institution needs to have a SOAP note example or template because it is very important for an institution to have a uniform format of organizing their patient’s medical information. This is for the obvious reason, if the institution has different formats, it can be very hard for someone else to understand the information in a patient’s chart. This clearly means that there are quite a number of advantages and disadvantages associated with the SOAP notes.SOAP Note And eMedley Entries Essay

Consider writing your SOAP note with the help of professional services:

Advantages
It has already been mentioned that the main purpose of SOAP notes is to develop a uniform way of capturing patient’s information in a medical facility. It is, therefore, true to say that, the SOAP note not only provides a standardized format of recording patients information but also it serves to guide the health officers on understanding the patient’s main issue and developing the most accurate treatment so as to provide better treatment.

Apart from that, the SOAP note adopts the use of medical terms that everyone in the medical field understands. With this, the health officers are able to organize the patient’s information in a clear and concise manner.

Disadvantages
The common problem associated with the SOAP notes is that it employs the use of too many acronyms and abbreviations and that it is too concise which sometimes make it hard for people outside the medical fraternity to understand.SOAP Note And eMedley Entries Essay

Physiotherapists also find SOAP notes quite limiting because there has been no guidance provided on how they can handle the functional goals or outcomes.

With that in mind, we can now get to understand how to write a SOAP note. You should bear in mind that this is just a simple document that includes only four main components as mentioned earlier.

Writing a SOAP Note Step By Step
It is important to note that documentation plays a major role in the process of providing health care services. However, in most cases, this aspect is highly ignored since most of health care providers choose to adopt methods that are not specific and sometimes giving a very brief description that is quite vague making it for another person to even comprehend.

In as much as there is no guidance on the length and details of patient’s information that should be documented, one should understand that they need to provide enough and relevant information based on the case at hand. The following are some of the guidance given by the American Physical Therapy Association on the nature of the information that should be included in a patient’s documentation:SOAP Note And eMedley Entries Essay

The patient’s self-report
The details of the kind of intervention given
The used equipment
Patients response
Any complication or negative reactions
Factors that lead to an intervention change
Achievement of goals or objectives stated
Proper communication with other stakeholders i.e., health providers or the patient’s family.
As a health provider, you should always have in mind that your report will at one-point land in the hands of another health provider either when you are still handling that case or some years later when the patient seek health assistance. This, therefore, calls you to be cautious to ensure that you write it well. We have already mentioned the components of a SOAP note, it now time to have an in-depth look at them.SOAP Note And eMedley Entries Essay
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Writing the Subjective
In simple terms, this is the information provided by the patient in a narrative form about their problem in terms of the symptoms, disability, function, and history. It is therefore very detailed. This information not only comes from the patient, it can also be derived from other caregivers or family members.SOAP Note And eMedley Entries Essay