Question

Overview

WW is a 55 year old patient that had a bowel resection for a small bowel obstruction. Prior to being admitted with abdominal pain WW had no chronic health issues but did have a hernia repair 5 years prior, smoked a pack a day since age 20, drinks a couple of beers on the weekend watching sports. Lives with his wife of 25 years. Has 2 children, son is 22 in good health and lives on his own, daughter is 20 and in college. On workup in the ER it was found he had a bowel obstruction and he was taken to the OR for surgery. He is now postop day 1.

Take the following information and separate it into a SOAP note:

Surgical incision margins have slight erythema and are well approximated with staples, no dehiscence, no drainage Rates his pain at 3 when resting and 7-8 when moving. Continue maintenance fluids at a rate of 125ml/hour NS. Says the nurse helped him to the bathroom once already and it was a relief to get up but painful. AM labs: CBC: WBC 12,000, trending downward; Electrolytes: normal; BUN 16; creatinine 1.1; Hemoglobin 14.0 g/dl, hematocrit 40%. DOB: 9/20/65. Continue low molecular weight heparin for DVT prophylaxis. Vitals- T: 100.2F, BP- 128/82, P- 82, R-18. No red or tender areas on lower extremities. Postop day 1. 25 Kris Kringle Drive, Nome, Alaska. Will continue to monitor patient. WW states he hasn’t slept much since he came out of anesthesia. Encourage ambulation with assistance and use of the incentive spirometer. No signs of hematoma or seroma formation. Roger Rabbit. No abdominal pain when laying quietly in bed but hurts when he coughs or moves. Wants to know when he can eat and drink. Continue to monitor CBC, electrolytes, BUN, and creatinine daily as ordered. Lungs- Clear to bases with auscultation. CV- RRR, no murmurs or gallops. 834-1245. Says he has not had anything to eat or drink since surgery and has not passed gas.  Intake and out put from the last shift - 2000ml NS IV / 800ml out via foley, 200ml on his own after catheter removed. Temperature slightly elevated. Wants to know when visiting hours start. Leave compression stockings on.  No jaundice. Abdomen- mild distension, minimal diffuse tenderness, bowel sounds are active. Pain level a 7 with movement. Would like something cold to drink. Abdomen slightly distended with positive bowel sounds. Doesn’t understand why this happened. Will begin to advance diet to clear liquids when patient experiences flatus. Slight erythema around wound edges.

Take the following information above and separate it into a SOAP note:

Identifying data*

Subjective information*

Objective information*

Highlight abnormal findings*

Assessment*

Plan of care*

Answer 1

Writing the ponts only;Elaborate it as per need

(SOAP NOTE)

(S)Subjective :- -Chief complaints of pain-grade 3 in bed and 7-8 while moving.No abdominal pain when laying quietly in bed but hurts when he coughs or moves.

-

(O)Objective -WBC-12000(trending downward),Electrolytes Normal,BUN 16,Creatinine 1.1,Hb 14.0g/dl,Hematocrit 40%.Vitals- T=100.2F,BP-128/82,P-82,R-18 .Abdomen -mild distension,minimal diffuse tenderness,active bowel sounds.

(A)Assessment :-Slight erythema aroudn wound edges.No dehiscence.No drainage.

(P)Plan :- Continue maintenance fluids at 125ml/hr.Continue monitoring CBC,electrolytes,BUN and creatinine daily as ordered.

Include more points if left any.Under subjective,you have to write about chief complaints and present illness mainly along with medications.Under Objective,you have to include all the lab results and vitals.Under Assessment you have to write about the differential diagnosis.Under plan,you have to right your plan strategy towards maintaining the disease.