-
Subjective
- CC, HPI, PMH, SH, FH, ROS, Allergies, Medications
- Descriptive, cannot be measured directly
-
Objective
- Physical Exam, Vital signs, Laboratory tests, CrCl, Serum drug conc., Diagnostic test results, Medications
- can be measured, often numerical
-
Assessment
- Disease Assessment + Supporting Evidence
- -Uncontrolled asthma secondary to improper medications use as evidenced by RR of 24 and history of smoking
- GOALS
- -Clear, achievable, and measureable, guidelines, communicated
-
Plan
- Pharmacologic
- -Drug, Dose, Route, Schedule, Duration
- Non-pharmacologic
- Education/Counseling
- Monitoring/Foloow up
- Rationale
-
Tips for SOAPs
- Includes your name and date
- Shor and to the point
- do NOT include unnessessary info
- BP, RR, HR, CrCl
-
Importnace of documentation of SOAPs
- Valuable communication tool
- Permanent record
- Legal record
- Back-up for billing purposes
-
PMS(Pre-menstrual syndrome)
- 4-10 days prior to menses
- Primary Dysmenorrhea
- Secondary dysmenorrhea
- Premenstrual dysphoric disorder (PMDD)
-
PMS treatment
- PMDD or secondary dysmenorrhea-Referral
- Symptomatic therapy: Analgesics, Pyridoxine (Vit B6), Pyrilamine or pamabrom, Caffeine
-
UTI
- Dysuria: painful, burning sensation while urinating
- Hematuria: blood in the urine
- Pyelonephritis: kidney inflammation due to bacterial infection
- Treatment: antibiotic, phenazopyridine(Azo) for symptomatic relief
-
Vulvovaginitis (Types)
- Candidal infection: think, curd-like discharge wiht yeast-like odor-OTC
- Bacterial infection: thin or creamy discharge with fishy odor
- Trichomonal infection: Copious, fothy discharge
- Atrophic vaginitis: Blood-tinged discharge
-
Vulvovaginitis (Assessment)
- Dyspareunia: painful sexual intercourse
- Vaginal dryness: Atrophic vaginitis
- Medication can predispose the patients
- yeast infection
- Postmenopausal women can have atrophic vaginitis
-
Menopausal symptoms
- 12 months between 48-55 yo
- Symptoms: hot flashes, flushing, sweating, disturbances in sleep, vaginal dryness or atrophy
- Thromboembolic events or breast cancer, niacin
- HRT, Osteoporosis
-
Pregnancy
- Leukorrhea: increased vaginal secretions
- Amenorrhea: absence of menses
- Heartburn, Edema, and etc.
- Gravida: total number
- Para: outcomes
- Refer when: vaginal bleeding, cramping, persistent headache, visual changes, 5% weight loss
-
Hormonal contraception
- If side effects last longer than 3 months: referral
- Side effects: Breast tenderness, nausea and vomiting, abnormal menstrual bleeding, breakthrough bleeding, vginal dryness, vaginitis, weight gain, acne
- Refer immediately: severe abdominal pain(pancreatis), chest pain, severe headaches, vision issues, DVT
-
General info for chart
- No scratch,erase
- Contents: Admission data, History and physical, Physician Orders, Lab Results, Progress Notes, Nursing Notes, Procedures/Consults, MAR
- (AHPPLPNPCM)
-
Morbidity
Disease or disability
-
Types of prevention
- Primary: Immunization, education
- Secondary: early detection, screening
- Tertiary: Reduce impact of disease (med use)
-
Evidence-based recommendations
- A: strongly recommends
- B: recommends
- C: no recommendation for or against
- D: recommends against
- I: insufficient evidence to recommend for or against
-
5 A behavioral counseling framework for tobacco
- Ask about tobacco use
- Advise to quit through clear, personalized messages
- Assess willingness to quit
- Assist to quit
- Arrange follow-up and support
-
Alcohol counseling
- AUDIT, CAGE, TWEAK, T-ACE
- CAGE: Cut down, Annoyed, Guilty, Eye-opener, more than 2 = alcohol dependent
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