Communication

including history taking, documentation...

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It can be a daunting prospect; the thought of writing in medical notes as a nurse practitioner and them being scrutinised by senior colleagues. To aid in the process of documentation, a SOAP approach can be used.  SOAP is a method of documentation originally developed for physicians in the 1960's by Dr Lawrence Weed at the University of Vermont. However, it is now used as an important documentation writing tool for all healthcare providers.
Using SOAP documentation provides a methodical approach to writing clinical notes. They enable the practitioner to produce written evidence of patient contact and outline their clinical decision-making process.
The four elements of SOAP are:
Subjective
Objective
Assessment
Plan
Each element of the SOAP should be explored in the specific order of the acronym.
Subjective: this relates to the information provided to the practitioner by the patient and should include:
the patients presenting complaint (PC) in their own words
the patient's history of presenting complaint (HPC)
can use SOCRATESor OLD CARTS
include tests, referrals, treatments and outcomes
past medical and surgical history
can use the mnemonic JAM THREADS
previous operations or procedures
previous anaesthetics and treatments
vaccination history
family medical history
social history
smoking
alcohol
drugs
diet and exercise
occupational history
travel history
sexual history
review body systems
 Objective; this relates to the information from observations, examination and test results such as:
vital signs and measurements including height and weight
examination findings
laboratory test results
radiology results
medication lists from pharmacy, GP or medical records
Assessment; this includes advice for lifestyle changes, your diagnosis and differential diagnosis.
Plan; this is where you include your plan of treatment including:
operation/procedure
medication
further tests
education
follow-up.


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