SOAP notes detail the findings that a physician receives after an interaction with a patient. These notes form the main conclusions that the writing physician rates as relevant and helpful to another health care practitioner to provide the necessary treatment to the patients (Morreale & Borcherding, 2013). Therefore, SOAP notes become a channel of exchange of information among the physicians, thus necessitating the need to ensure that the details captured in the notes are appropriate since they profoundly influence the nature of the treatment plan given to the patient by another physician. In nursing, since the adoption of the Affordable Care Act, the call has been for the nurses to employ the art of evidence-based action in their line of caregiving (Thompson, 2015). Therefore, to the receiving nurse of the SOAP notes, the relevance and effectiveness of the treatment plan given to the patient depend on the evidence availed from a professional viewpoint in the SOAP notes. Appreciating the significance of the information availed, one needs to ensure that the information captured in the SOAP notes is accurate, thorough, and guided by the information captured in the meeting in addition to professional assessment by the physician. This is a crucial form of a communication channel between physicians and should capture in great depth all the relevant information. This paper intends to come up with the SOAP notes on a disease called diverticulitis. It is guided closely by the pharmacology discipline in the line of ensuring that the affected patient receives the right help at the right time – a phenomenon highly agitated in the new norm of nursing under the guidance of Affordable Care Act.
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Patients Name: ……………………………………………… Date: …………………
The patient aged 43 came into the hospital with the complaints of abdominal pains that had worsened with time. The patient mentions that he has been coping with the pain for the last three weeks, but the pain has increased despite the use of painkillers. Pain is particularly concentrated in the bottom left part of the abdomen. The patient also mentions that the abdominal pains are sometimes accompanied by nausea, constipation, and fever. Moreover, the patient rates his current level of pain at 8/10.
Past medical history. The patient did not have any relevant historical cases related to abdominal pains.
Family medical history. The patients sister suffers from ulcers and she is on constant medication to suppress the disease. Moreover, the mother suffered from stomach cancer at the age of 45. His father died as a result of a stroke.
Social history. The patient is married; he has three children and he rarely consumes alcohol. Moreover, he is a member of Walking for Health, a club where members have to walk for 4 kilometers on subsequent Saturdays.
General overview. The patient has recently lost appetite due to the phobia of the after meal pains.
BP. 127/87 17 Breaths per Heart minute beat per minute 76 T. 98.62 F
ENT: a clear throat, well moist mucous membranes.
The patient is respective and keen on providing details; besides, at first sight, the patient seems not to be suffering from any pain.
Abdominal area shows no physical scarring. Pain is primarily concentrated in the lower left abdomen.
Arms, legs are fully functioning without any discomfort.
Spleen and liver are normal.
Bases on the subjective and objective feedback, the following are the possible diagnoses.
Acute Diverticulitis (1)…. Abdominal pain on low left abdomen
Gallstone disease (2)……..Abdominal pain
Peptic ulcer disease
Due to the presence of serious abdominal pains and with the primary diagnosis being acute diverticulitis, medical therapy is necessary. A sonogram will be required to clarify the issues in the abdomen to identify whether there is any inflammation. Having this clarity will help in the classification of the problem and coming up with the relevant pharmaceutical therapy. If the confirmation is in line with the assessment that there is a high possibility of the patient suffering from acute diverticulitis, the primary pharmaceutical therapy should be antibiotics as outlined below.
Oral medications. The combination of Amoxycillin + clavulanic acid will be very helpful in treating bacteria-based infections. Sulfamethoxazole-trimethoprim is also a combination that can be effective when it comes to killing sensitive bacteria (Tursi, 2010). However, these drugs should be dispensed together for improved effectiveness. Therefore, metronidazole, a drug well known to treat anaerobic bacterial infections, can be prescribed as well.
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Intravenous medication. The treatment plan can be formed in an emergency situation due to the severity of the pain, as mentioned by the patient. If this is the case, an intravenous route will be utilized in the medication of the disease, where any of the following drugs will be utilized – Clindamycin, Aztreonam, ampicillin-sulbactam, or Association of several ?-lactamase inhibitors (Tursi, 2010). Moreover, it will be of importance to guide the patient on how to make the necessary diet changes to incorporate food with more fiber and low fat. All the above drugs can be utilized in the treatment but they cannot be used together. The rationale for the use of antibiotics is because a majority of abdominal pains is caused by bacterial infections (Sierpina, 2010).
As shown above, SOAP notes are a crucial component in the treatment process since they avail assessment findings in an organized manner, making it possible for the treating physicians to identify the possible disease at hand and come up with a speed treatment plan that might be needed. Moreover, the notes contain all the necessary information in a manner that has captured the needed depth in a concise form, making it possible for the receiving physician to understand and make the necessary steps (Morreale & Borcherding, 2013). As demonstrated above, SOAP notes have four universal components containing different information. The subjective component forms the feedback attained during the first meeting between a patient and the caregiver (Morreale & Borcherding, 2013). Of importance to appreciate is the fact that information under the subjective component emanates from the patient, and if the patient is incapacitated, this information comes from the representative of the patient. Information captured includes, but it is not limited to, the medical history of the patients, the medical history of the family members of the patient, social lifestyle, and the general conclusive take on the condition at hand. In the case at hand, the patient did not have previous similar incidences, he was actively involved in physical activities, and his mother had suffered from stomach cancer.
On the other hand, the objective component is formed by the pool of assessment and tests done to the patient by a qualified physician. In the case at hand, this information is captured in the heartbeat rate (76/min), 17 Breaths per minute, BP (127/87), and a temperature of 98.62 F. This information is helpful for the diagnosing physician to apply the selective policy in identifying the disease (Morreale & Borcherding, 2013). Assessment is the other component, whereby a list of potential diagnoses in chronological order is presented. The inclusion of different possible diagnoses is caused by the fact that additional tests are needed at this stage to clarify on the disease, which the patient might be suffering from, in a comprehensive manner. In the case at hand, potential diseases that attract abdominal pains are listed and they may include Acute Diverticulitis (1), Gallstone disease, and acute appendicitis. Lastly, the plan is another component that captures the physicians treatment plan that will be utilized to solve the problem of the patient (Morreale & Borcherding, 2013). Clarification of the diseases is done here, and the potential treatment approaches are outlined. In the case at hand, a sonogram forms the tool that will be utilized in defining the disease. A potential treatment plan is outlined as well as the potential forms it may take. In the case at hand, the illustration example is the fact that the patient has acute diverticulitis, and the primary treatment is the pharmaceutical therapy that includes the utilization of antibiotics such as Amoxycillin + clavulanic acid or Clindamycin. These illustrations paint a clear picture of the crucial role SOAP notes play in the treatment process, thus necessitating due diligence while one is compiling one.
It is evident that SOAP notes are a crucial form of communication between caregivers when they need to deliver the right help at the right time. It is also evident that when writing up a SOAP note, different types of information are presented in different components of the note. Furthermore, it is apparent that each element of the SOAP Note avails crucial information to the receiving physician that helps him or her take the right approach while treating the patient. Moreover, the patients or their representatives input plays a crucial role in shaping the direction adopted by the physicians to come up with the right SOAP note. Thus, it is evident that an inclusive, transparent, and definite SOAP note plays a crucial role in helping the treating physician come up with the right treatment plan and pharmaceutical therapy needed in the healing process of the patient.