In: Nursing
What would be the proper way to document an assessment from this case study?
Document of assessment from a case study is called SOAP, Subjective,Objective,Assessment and Plan
SUBJECTIVE
it includes documenting patient's name, and it is the subjective section ,wher we are to record the complaints of the patients in their own language. Try to record accurately and choronological order,the patients complaints. We can quote as the patient narrate if it is any specific symptoms for a particular disease eg:- heaviness in the chest it is specific for myocardial infarction
OBJECTIVE
It includes the recording of findings after clinical examination and record system wise
here we have to record what we see, feel, measure and hear
General appearnce:- record height,weight, calculate BMI,
Vital signs:- Pulse rate, BP, Respiration
fluid balance:- hydration, urine output
Cardiovascular system:-any visible pulsation, heart sounds
Respiratory system: look for wheeze, air entry in all lung fields bilaterlly
Gastrointestinal system:-look for abdominal distension, visible pulsation, dilated veins , bowel sounds
Central nervous system:- any focal defecit, movements and motor power
Laboratory investigations:- blood tests, ECG,Echo,EEG
ASSESSMENT:-
come to a diagnosis
eg: if the patient came with complaints of chest heaviness, on objective findings tachycardia, raised blood pressure, and on ECG there is ST segment changes you can come to a diagnosis of Acute Coronary Disease
PLAN
how we are going to manage the patient
this includes :-
further consultation required if any\
medications
further investigation if needed