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What I NEED IS A SOAP NOTE You are a medical assistant in

Customer Question

What I NEED IS A SOAP NOTE

You are a medical assistant in a large physician practice that is going to be growing by adding additional physicians. The practice will need to hire and train quite a few new medical assistants to support these new physicians. They have contacted a local college to allow them to post ads in the medical assisting program to recruit new graduates to these positions.

The office manager decides that the practice needs a process to help determine what additional training may be needed for new hires. You are part of a team that has been asked to identify a way to help new hires identify areas where they will need additional training.

Your group decides to give new hires the opportunity to demonstrate their knowledge of medical terminology and meet with the office manager to determine additional training needs based on their performance analyzing a SOAP note.

Instructions:

Individual Deliverable: Each member of the group should write a brief SOAP note of at least 4 paragraphs documenting a fictional patient visit and including medical terms with suffixes, roots, and prefixes. The individual member should select a digestive or integumentary system patient problem that the medical terms will refer. Go to the Library and use the web resources to help you develop your SOAP note. Use your knowledge of other medical terms to develop a SOAP note too.

For the assessment part of your note, write a summary of the findings rather than a medical diagnosis. For the plan, you can note what medical terms seem realistic to use in terms of follow-up. The goal is to develop a document where the new hire can demonstrate his/her knowledge of medical terminology. When you encounter abbreviations or acronyms that you are unfamiliar with, you may use your own resources or the web links below to determine the meaning of those abbreviations or acronyms. Your individual deliverable should identify acronyms or abbreviations that could be misinterpreted and how you have modified your SOAP note to avoid that possible misinterpretation. For example, one of the acronyms used in one of these SOAP notes refers to the acronym SBE. This can mean self-breast examination, which is also seen as BSE (breast self-examination) or an illness called sub acute bacterial endocarditis, referring to an infection of the heart. Obviously these have very different meanings.

Please add your file.

Group Deliverable:

Your group should combine features of the individual SOAP notes into one SOAP note to describe a fictional patient visit. There should be at least 10 medical terms used and terms from at least 2 body systems should be mentioned. Remember that patients who visit a certain kind of physician may have current medical problems in other body systems. The new hire will be asked to analyze each term using suffixes, roots, and prefixes. He/she will also be asked to describe the literal meaning, actual clinical usage, and the pronunciation of each term.
Submitted: 4 years ago.
Category: Health
Expert:  Dr. Owen replied 4 years ago.

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Hello, and I am pleased to help, use of my answers are for educational purposes only.
Is this for homework?
Do you need a SOAP note written?


Edited by Dr. Wilson on 9/14/2010 at 2:17 AM EST
Customer: replied 4 years ago.

YES I NEED IT FOR A MEDICAL TERMINOLOGY CLASS THIS IS WHAT I NEED

 

 

Instructions:

Individual Deliverable: Each member of the group should write a brief SOAP note of at least 4 paragraphs documenting a fictional patient visit and including medical terms with suffixes, roots, and prefixes. The individual member should select a digestive or integumentary system patient problem that the medical terms will refer. Go to the Library and use the web resources to help you develop your SOAP note. Use your knowledge of other medical terms to develop a SOAP note too.

For the assessment part of your note, write a summary of the findings rather than a medical diagnosis. For the plan, you can note what medical terms seem realistic to use in terms of follow-up. The goal is to develop a document where the new hire can demonstrate his/her knowledge of medical terminology. When you encounter abbreviations or acronyms that you are unfamiliar with, you may use your own resources or the web links below to determine the meaning of those abbreviations or acronyms. Your individual deliverable should identify acronyms or abbreviations that could be misinterpreted and how you have modified your SOAP note to avoid that possible misinterpretation. For example, one of the acronyms used in one of these SOAP notes refers to the acronym SBE. This can mean self-breast examination, which is also seen as BSE (breast self-examination) or an illness called sub acute bacterial endocarditis, referring to an infection of the heart. Obviously these have very different meanings.

 

Customer: replied 4 years ago.

Hi Doctor Wilson

 

I need to have the soap by today is that possible? can you e-mail me and let me no if that is possible

Expert:  Dr. Owen replied 4 years ago.
I am an ob/gyn - I can give you a good SOAP from the prospective of an ob/gyn that contains 2 body systems - is that okay?
Customer: replied 4 years ago.
yes can you do it today
Expert:  Dr. Owen replied 4 years ago.

S: 21 yo (year old) WF (white female) G2P1001 (Gravida 1, Para 1001 – she has delivered one child at term), with complaint of RLQ (Right Lower Quandrant) Pain for the past month, and more pain during intercourse. The pain is sharp and buring. She has no diarrhea, no constipation. She does c/o (complain of) Pelvic pain for the past 1 year, but supposedly has no history of STD’s (Sexually Transmitted Diseases). Also, she has no N/V/F (nausea/vomiting/fevers).

O:

VSS (Vitals signs Stable), Afebrile

HEENT (Head, Ear, Nose, Throat) – NC/AT – (Normal Cephalic/Atraumatic)

Lungs: CTA B (Clear to Auscultation bilaterally)

ABD (Abdomen): +BS – (positive bowel sounds), TTP (Tender to Palpation), +Rebound,

Pelvic: NEFG (Normal External Female Genitalia), CVX (Cervix) – with discharge, pus and odor; +fullness to pelvis on the right, +CMT (positive Cervical Motion Tenderness), R/V (Recto/Vaginal) – is full.

Ext (Extremities) – No C/C/E (no cyanosis, clubbing, or edema)

A/P: 21 yo WF G2P1001 with most likely CPP (Chronic Pelvic Pain) with possible Appy (appendicititis), Endometriosis, Ovarian Cyst, Ovarian Torsion, or PID (Pelvic Inflammatory Disease).

1. Cultures for STD, GC/CT (Gonorrhea/ Chlamydia)

2. Pelvic US (ultrasound)

3. Dx L/S (Diagnostic Laparoscopy)

4. Doxycycline 100mg po bid (100 milligrams to be taken by mouth twice per day)




I hope this helps, if you have more questions, please ask, and Please click on ACCEPT as this would be appreciated for my service to you and this is how JustAnswer compensates us, thank you.
Expert:  Dr. Owen replied 4 years ago.

S: 21 yo (year old) WF (white female) G2P1001 (Gravida 1, Para 1001 – she has delivered one child at term), with complaint of RLQ (Right Lower Quandrant) Pain for the past month, and more pain during intercourse. The pain is sharp and buring. She has no diarrhea, no constipation. She does c/o (complain of) Pelvic pain for the past 1 year, but supposedly has no history of STD’s (Sexually Transmitted Diseases). Also, she has no N/V/F (nausea/vomiting/fevers).

O:

VSS (Vitals signs Stable), Afebrile

HEENT (Head, Ear, Nose, Throat) – NC/AT – (Normal Cephalic/Atraumatic)

Lungs: CTA B (Clear to Auscultation bilaterally)

ABD (Abdomen): +BS – (positive bowel sounds), TTP (Tender to Palpation), +Rebound,

Pelvic: NEFG (Normal External Female Genitalia), CVX (Cervix) – with discharge, pus and odor; +fullness to pelvis on the right, +CMT (positive Cervical Motion Tenderness), R/V (Recto/Vaginal) – is full.

Ext (Extremities) – No C/C/E (no cyanosis, clubbing, or edema)

A/P: 21 yo WF G2P1001 with most likely CPP (Chronic Pelvic Pain) with possible Appy (appendicititis), Endometriosis, Ovarian Cyst, Ovarian Torsion, or PID (Pelvic Inflammatory Disease).

1. Cultures for STD, GC/CT (Gonorrhea/ Chlamydia)

2. Pelvic US (ultrasound)

3. Dx L/S (Diagnostic Laparoscopy)

4. Doxycycline 100mg po bid (100 milligrams to be taken by mouth twice per day)



I hope this helps, if you have more questions, please ask, and Please click on ACCEPT as this would be appreciated for my service to you and this is how JustAnswer compensates us, thank you.
Expert:  Dr. Owen replied 4 years ago.
I hope this was helpful
If you have questions please ask me.
Expert:  Dr. Owen replied 4 years ago.
Hello I did take the time to answer your question ...
Dr. Owen, Doctor
Category: Health
Satisfied Customers: 55753
Experience: Board Certified Physician and US Medical School Graduate
Dr. Owen and 5 other Health Specialists are ready to help you
Customer: replied 4 years ago.

Hi Dr Wilson the soap note is good but I was suppose to have

A definition of the term and analysis of each term

Describe the literal meaning

Explain the actual clinical usage of that term if those differ

Include identification and definition of the prefix, suffix and root terms

 

include either in parentheses after each medical term or in notes at the end of the assignment:

I ask you if you did this and you said yes I just look at it and their is part missing can you help me with this I would appreciated it please let me no if you understand

Customer: replied 4 years ago.

 

this is exmple of what I need please

 

Summary of Terms

Medical Term

Word Root

Combining Vowel

Suffix

Meaning

Gastralgia

Gastr-Stomach

 

Algia-pain

Pain in the stomach

Appendectomy

Append-appendix

 

Ectomy-excision of the

Excision of the appendix

Melena

Melen/a-black

 

 

Black, tarry stool that contains digested blood.

Gastroscopy

Gastr-Stomach

O-of the

Scopy-visual examination

Visual examination of the stomach

Cholelithiasis

Chol-gall

Lith-stone

E-of the

Iasis-condition

Condition of gallstones

Gastroplasty

Gastr-stomach

O-of the

Plasty-surgical repair

Surgical repair of the stomach

(Brooks, 2005).

Expert:  Dr. Owen replied 4 years ago.
I'm not sure what you mean by that last question - you asked for a SOAP note - and that is what I gave you -
Are you asking for me to 'define' the words, the medical terms I gave you in the SOAP note
?
Customer: replied 4 years ago.

YES YOU GAVE ME A SOAP NOTE. BUT IF YOU READ THE REST OF THE ASSIGNMET

 

YOU WILL SEE IT ALSO SAID TO DEFINE THE WORDS. AND THE MEDICAL TERMS AND

 

THE MEANING OF THE TERMS GIVE THE ROOT,SUFFIX,PREFIX.YES

 

THAT IS WHAT I NEED FROM YOU. LIKE THE EXMPLE I GAVE IT NEED TO BE IN A TABLE FORMAT I AM SORRY IF I DID NOT MAKE IT CLEAR ENOUGH FOR YOU CAN YOU GET BACK TO ME WITH IT TODAY? THANK YOU

Expert:  Dr. Owen replied 4 years ago.

Summary of Terms

Medical Term

Word Root

Combining Vowel

Suffix

Meaning

Genitalia

Genital – sex organs

-alia : portion

Sex organ of female/male

Cervical

Cervix

n/a

Opening to uterus

Appendicitis

App - appendix

-citis - inflamation

Inflammaed/infected appendix

Laparoscopy

Laparo- cavity

O-of the

Scopy-visual examination

Visual examination of the stomach/ pelvis

Endometriosis

Endo - Internal

O – of the

Metriosis – middle inflammation

Uterine cells that have escape and irritating the internal pelvic/abdominal cavity

Auscultation

Auscul - hear

- tation – process of

To hear via stethoscope

Customer: replied 4 years ago.
Thank you so much
Expert:  Dr. Owen replied 4 years ago.
Your welcome - any time
Customer: replied 4 years ago.
Hi Dr can you take a look at my question please

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Expert:  Dr. Owen replied 4 years ago.
I am - what do you specifically need.
I wrote a fairly detailed SOAP note and even explained all the acronyms.
I understand that teachers want things that are unusual, so explain what you need - but don't repeat the entire question.
Just ask me what you need.
Customer: replied 4 years ago.

 

Here are the instructions from the teacher

 

 

 

:

Grading Rubric For Week Five

Assignment 1

Deliverable Length: 5-10 paragraphs

Points Possible: 150 Due Date: 09/26/2010 11:59:59 PM Description:

 

Measurable Terminal Course Objective:

Interpret medical terms related to the individual systems and the body as a whole.

The key here is to make this "user friendly". The language should be able to be read by a grade school student. There should be no medical terms used

There are 150 points in this assignment. I would suggest that you go to the library and online or to a physician's office or Public Health Department (grocers also carry informational brochures), pick up a brochure on heart health to see what it is like, and to look at the language they use.

They are graded as follows:

Expert:  Dr. Owen replied 4 years ago.
This is not the original assignment - I don't understand what you are asking for - is this a new assignment. Are you confusing me with someone else.?
Customer: replied 4 years ago.

yes this a new question I was asking you to look at I posted it the Question but here it is

 

 

5-10 paragraphs
Details:

You work in the office of a cardiologist. He has asked you to develop a draft of an initial patient education brochure to help patients who have had a myocardial infarction. He has jotted some notes, handed them to you, and asked you to make them "patient friendly."

Instruction

Read the following information he has provided. Write a patient brochure using simple, easy to understand language.

After Your Myocardial Infarction

(briefly describe the anatomy and physiology of the cardiovascular system and how the heart functions)

Your Myocardial infarction was caused by several factors including hypertension, atherosclerosis, and cigarette smoking. This pamphlet will help you understand how these factors can affect your heart and how to modify your lifestyle so you can decrease your risk of another myocardial infarction.

Hypertension causes injury to the endothelium of your arteries and lipids and other substances accumulate in those injured areas. This contributes to thrombus formation, which occluded your artery causing a myocardial infarction.

Hyperlipidemia is another contributing factor, as LDLs that are the "bad cholesterol" contribute to development of plaque buildup in the artery.

Cigarette smoking causes increased heart rate, peripheral vasoconstriction, and hypertension increasing the amount of work the myocardium has to do. Cigarette smokers also inhale carbon monoxide, which decreases oxygenation of hemoglobin. These factors cause the myocardium to work harder while hypoxic.

Because you had an angioplasty and atherectomy, your affected artery has been opened to allow improved perfusion.

During your next appointment, please schedule extra time to talk with the nurse about how you can modify your lifestyle to decrease you risk of having another myocardial infarction.

Expert:  Dr. Owen replied 4 years ago.
You might want to repost this question to a new question - I don't have the time right now to answer this for you. PLus, I am not a cardiologist - and you might an Internal Medicine or Cardiologist to answer this - so when you post a NEW question, ask for a Cardiologist OR an Internal Medicine doctor only.
Customer: replied 4 years ago.
Thank you Dr Wilson

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Expert:  Dr. Owen replied 4 years ago.
Your welcome.

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