السلام عليكم ورحمة الله وبركاتهSOAP notes are a method of charting employed by nurses and other health care professionals. They provide an all-inclusive record of patient interaction, as well as help to standardize charting amongst health care professionals. SOAP notes are also popular because they are easy to review for quality assurance, and they are easy for receptionists, coders and lab technicians to understand, should they need to read or interpret the patient's chart. They paint a complete and accurate picture of the entire visit.
طريقة كتابة الملاحظات المطلوبة بناء على معايير CBAHI
Read more: How to Write a Nurse's SOAP Note | eHow.com
1. Write the "S" or subjective section. This includes everything the patient reports. Information in this section usually relates to the patient's complaint in his own words and includes any reported symptoms, their severity and their duration.
Write the "O" or objective section. This section details any information you observe while listening to the patient's complaints and performing an examination. If you notice ankle swelling as the patient reports pain, this is the section where you record it
3.Write the "A" or assessment section. Here, you include your diagnostic nursing assessment, as well as any lab test results you perform. If you are monitoring rather than assessing a patient, you Note any changes in the patient's condition here.
4.Write the "P" or plan section. This is the plan for treatment, including what medications or other therapies you will administer or advise. This section should be actionable and thoroughly map out the course of treatment, as well as the intended outcomes and any necessary follow-ups, referrals or additional testing that is needed.
SOAP Note Example- Problem Visit
SOAP Note Example
الكفاح جزاكي الله الف خير
موضوع في قمة الخيااال
دمت ودام عطائك
ودائما بأنتظار جديدك الشيق
لك خالص حبي وأشواقي
سلمت اناملك الذهبيه على ماخطته لنا
اعذب التحايا لك
لكـ خالص احترامي
| || |
موضوع رائع تراي فهمته
أشكرك غاليتي وتقبلي مروري
لك الشكر على الطرح القيم
|مواقع النشر (المفضلة)|
|الكلمات الدليلية (Tags)|
|how, note, nurse's, soap, write|
|أدوات الموضوع||إبحث في الموضوع|
|انواع عرض الموضوع|