OLDCARTS O- Onset when did the issue arise L- location of the pain D- Duration how long has the pain been going on for C- Characteristics is it throbbing, radiating, piercing pain A- Aggrevates what makes the pain worse R- Relieves what takes away the pain or lightens the pain T- Treatments have you taken any medications for the pain or issue S- Scale of 0 to 10 0 being no pain 10 being the worst pain imaginable what number do you fall in
@@stefainepatricio9559 It would be subjective, as it is the patient telling you. You wouldn't be able to determine any of these, thus meaning it wouldn't be objective. Subjective, as well as objective, allows you to come up with a plan.
Thank you so much for for this I’ve been searching for this for a very longtime and you’ve got the best version of it 👏 Now I know how to write soap notes.
omg You are the best. I love the video and how simple you make everything look and sound. I am currently at Fort Sam and have to go through this in order to be a Navy Corpsman and this part is the only thing that sounded confusing UNTIL now lol thanks again
omg You are the best. I love the video and how simple you make everything look and sound. I am currently at Fort Sam and have to go through this in order to be a Navy Corpsman and this part is the only thing that sounded confusing UNTIL now lol thanks
At the end of this video you mention going into more detail for the NP students. Can you post the link for that video? I love your lectures! So easy to follow yet thorough!
This video was posted 4 years ago, here I am today, 4 years later Thanking you tremendously for, doing the Lords work🙌🏽🙌🏽 😂😂(No seriously) I’ve been reading, researching, & pondering my blood pressure for an entire week trying to find an explanation of documentation In layman’s terms of S.O.A.P notes!! Thank you! thank you thank you!
Hey Jessica, this is Lami here.. I wanna tell u that I am very much impressed by your videos.. please keep updating this channel with more n more videos. These are really helpful, am looking forward for more informative uploads from you. THANKYOU n keep up the great work ! Regards! :)
I can't thank you enough for this video like i was literally searching for a video that includes how to exactly write a case based soap note and i finally found this video. Thank you so much❤️
I don't know if you ever read these reviews anymore, but I met you in 2009 right after you had your daughter. I am currently in school for nursing and I saw your name and I thought...WOW, what are the odds! Hope this note finds you well :) This was a super helpful video btw
Hi Jess! I love your videos! Thank you for putting the time and effort into them. Question:is this the video for the FNP students? You had mentioned that a more detailed/expansive video would be coming that was meant for FNP students. Is this the one? Thanks much!
Hi Elizabeth... I think I had intentions to do another video, but never got around to it. My 'to do' list got away from me for the last several years :) Thanks for watching. If you subscribe then you'll be notified when more videos are published. Aloha- J
Jessica Nishikawa , I'm wondering your opinion on an educational phenomena. There are a plethora of online FNP programs now, turning out literally thousands of new FNPs. How do you recommend FNP students develop that mastery of physical exam skills, when in an online program (in which all content is in a distance learning environment, except for clinical hours w/preceptor). How can the online student develop PE proficiency, BEFORE their clinical time under a preceptor? Ideas? Want to start a "Hawaii Boot Camp" for FNP students?!?! 😉
Hi Libby, if you are in a FULLY online program it can be challenging! You can try virtual patient experiences (iHuman or others), they will help develop clinical reasoning but not much actual physical examination techniques. You should also examine as many of your friends and family members as you can - until they're sick of you :) It will help a lot. Is there an NP school near you? You could try to get in on their study sessions. Wish you the best!
I am guessing that an RN SOAP note would be different as far as the assessment part goes since nurses don't diagnose. In this case would a nursing diagnoses be part of the assessment?
You are correct! as an RN you would use nursing diagnosis. In the case of the sore throat, for example, you could use "impaired comfort r/t sore throat" or "impaired oral mucous membrane r/t inflammation or infection of oral cavity", etc.
Thanks for the video! Very helpful! May I ask a question? Do doctors always take the patient's review of systems, family history, social history etc. every consultation? Wouldn't it be redundant? Or do they keep a record of it? Awesome video!
Hi Harell Juanico, thanks for watching! To some degree clinicians ask these questions on most patient encounters. Usually we keep it focused and only ask the part of those questions that is related to the reason they are being seen for that visit. The comprehensive past medical, family, social history and the comprehensive ROS can be updated annually or as needed, and then referenced. Good question!
Hi Dede, Sorry this is late reply. This particular video is made with an endless whiteboard program called VideoScribe. It's great and very user friendly! Thanks for watching! :)
Hi Rebecca, Sorry I am getting to this message late. "Billed for" refers to the medical diagnoses that get submitted to insurance companies to support the billing for a patient encounter. As a medical provider in the United States you have to code your visits and then submit support for that code. Thanks for watching.
I'm not sure if this is such a big deal but I've been taught to never write "denies HA, Rhinitis, etc" and instead to write "reports absence of HA, Rhinitis, etc"
Define and List subjective data in pain assessment. Chief complaint history of present illness past medical history social history 2. Define and List objective data in pain assessment. Record physical findings vital signs general survey gent lymph 3. List 10 possible causes of discomfort. 4. List several methods for pain control.
It would :) Did I not mention it? I tend to leave it out of day to day practice because most of the people i work with are older adults and I find it a bit ironic to ask a 90 year old if their parents had any cancers or major medical history. :)
Hi there - I work in curriculum design and would like to use this video as part of the background information for an assignment I am putting together. I didn't see any contact info for you, but may I have your permission to use this video? I can explain further via email.
This is SOAP notes for beginners so there are simplifications. Follow these steps though and no one will ever question your SOAP note structure.. You can certainly put information in many other sections as well as you become more versed in medical documentation. But to address your specific statement/questions, those things are subjective if the patient is telling that information to you. Ie: new patients, new patients to your group, history taking, etc. If you are seeing the patient have an allergic reaction, you would put your examination findings in the objective information. It's easiest to think of everything as subjective except for what you are seeing/examining (objective). Thanks for watching! J
@@JessicaNishikawa Subjective is how the patient describes the symptoms of a disease / injury and their current physical /mental state according to their perception. Subjectivity does not extend into their name, age, sex, meds, PMH, PSH, allergies as those are facts. For example, subjectively they may say they are in pain but objectively there is no sign of trauma or any evidence of pain. You cannot say that subjectively they are a 62-year-old male but objectively this is a 25-year old female because you would just state a fact of their identity. You would explicitly state that "patient identifies as a 62-year-old male who is, in fact, a 25-year-old female" What you did was to mix in a 1 - 3 sentence patient introduction with subjective information. This is what makes the SOAP note confusing to others when people mix a bunch of stuff together and call it "subjective".
@@splitaxis Thank you for weighing in with your opinions. Within the confines of a SOAP note, in which section do you suggest students put that other information.
@@JessicaNishikawa John is a 62-year-old male with a PMH of diabetes who presents today with foot pain. SUBJECTIVELY he describes the pain as ba bla bla bla bla. OBJECTIVELY his vital are bla bla bbla and his physical exam is notable for bla bla. The style is really 1 -3 liner intro followed by SOAP. This is why so many notes include name age and sex in subjective parts in EPIC even though they don't belong there at all. It really should be ISOAP but that doesn't sound as good.
@@splitaxis Sure! That works. You'll find out in practice it actually doesn't matter where the information is as long as the billers can find it... but organization is helpful to easily identified information for future reference.
Hi HOME Guys, thanks for watching and taking the time to comment. If you were watching a little more carefully you would notice that the lisinopril wasn't actually increased. It was Lisinopril 20mg and at the end was still lisinopril 20mg (insert shrug emogi). Which was actually an oversight :) But one I didn't think required correction since the video is not about HTN management but about how to write a SOAP note (see clever title and video intro). If you're looking for videos about hypertension management I could recommend resources, just let me know. Aloha!
