Question

S: patient return after undergoing upper GI; not in as much discomfort as last visit. states he has been taking clear liquids and soft foods. say he is hungry.
O: lab results are back. Chem 7 shows slightly elevated glucose at 133. CBC and UA normal. Upper GI shows two small areas of ulceration.
A: Gastric ulcer.
P: Reduce omeprazole to 10 mg every day. Recheck glucose at return visits in 4 weeks.
E: Patient was advised not to smoke or chew tobacco, limit alcohol intake, and avoid aspirin, ibuprofen, and naproxen. Try acetaminophen instead. No diet restrictions indicated.
R: Patient was relieved, indicated there is no problem following the above plan and recommendation. MM/tim

what can information due you want

can you help me or not

the lab assignment is going to take a little creative thinking as the medical assistant you play a role in the completeness of the patient's medical history most office use either the soap or soaper method to document the medical history in the medical records you are going to practice one of these documentation method by creating a fake patient complaint and responses to one of the above choice (Soap or soaper)

Answer 1

The soap fomat has 4 parts subjective, objective, assessment and plan . The soap for the upper GI surgery is

S= the complainsts of pain in the surgical site, and looks very tired

O= on assessing surgical wound the site looks infective with redness, hot to touch and painful, the blood tests done to know is there any underlying infection

A= the assessment of the overall condition of the pt as why he develop the wound infection , what are the causes of the surgical wound infection, what pt is doing that causes this infection

P= the plan of action is to provide the medications for the infection, teaching how to take care of surgical site ,proper handwashing and precautions taken to dress the wound