Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note
Gynecologic Health
Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :
Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.
Very Important: Reflection notes: What would you do differently in a similar patient evaluation?
Reference
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)
Chapter 7, “Care of the Woman with Reproductive Health Problems”
“Care of the Woman with Dysmenorrhea” (pp. 366–368)
“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)
It is widely taught that diagnosis is revealed in the patient’s history. ‘Listen to your patient; they are telling you the diagnosis’ is a much quoted aphorism.
The basis of a true history is good communication between doctor and patient. The patient may not be looking for a diagnosis when giving their history and the doctor’s search for one under such circumstances is likely to be fruitless. The patient’s problem, whether it has a medical diagnosis attached or not, needs to be identified.
It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned as part of the comprehensive and systematic clerking process outlined in textbooks. A good history is one which reveals the patient’s ideas, concerns and expectations as well as any accompanying diagnosis. According to 6551 WK 3 SOAP assignment, The doctor’s agenda, incorporating lists of detailed questions, should not dominate the history taking. Listening is at the heart of good history taking. Without the patient’s perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.
Often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A good example is with the complaint of headache where the diagnosis can be made from the description of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations.
To obtain a true, representative account of what is troubling a patient and how it has evolved over time, is not an easy task. It takes practice, patience, understanding and concentration. The history is a sharing of experience between patient and doctor. A consultation can allow a patient to unburden himself or herself. They may be upset about their condition or with the frustrations of life and it is important to allow patients to give vent to these feelings. 6551 WK 3 SOAP assignment states that, The importance of the lament and how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool for both patient and physician, has been discussed in an excellent paper[5].
The skills required to obtain the patient’s true story can be learned and go beyond knowing what questions to ask. Indeed ‘questions’ may need to be avoided, as they limit the patient to ‘answers’. There is a lot written about consultation skills and different models of consulting. These have been developed through consultation analysis and now form an important part of undergraduate medical training and GP training in the Curriculum for Speciality Training for General Practice. There are many examples of aspects of consulting which may assist history taking for doctors working with patients in all specialties.
Setting
- The layout of the consulting room can assist good consulting. It can facilitate establishing rapport with patients by, for example, allowing for good eye contact, enabling easy access to computers or notes and avoiding ‘distance’ between the doctor and patient.
- Take care with the opening greeting, as this can set the scene for what follows. It may assist or inhibit rapport. Generally, it helps to be warm and welcoming so as to put the patient at ease. Good eye contact, shaking hands with the patient and showing an active interest in the patient should help to establish trust and encourage honest and open communication.
- Take care not to let the computer intrude on the consultation. This can be difficult when there is useful information available on a screen. Make use of the time before and after consultations to obtain information from the computer.
Listen first and listen second
Let the patient tell you the story they have been storing up for you. This can be encouraged by active listening.
- This implies that the doctor is seen to be interested and attentive by the patient.
Give the patient a chance to tell you their pre-constructed narrative, rather than diving in with a series of questions to delineate detail (such as the exact frequency and colour of their diarrhoea). according to 6551 WK 3 SOAP assignment, this approach affords a better chance of obtaining a true ‘flavour’ of their experience of an illness, its temporal development and the relative importance to the patient of the symptoms that they have (which ultimately is what, from their viewpoint, you’ll be attempting to cure, not ‘the diagnosis’, about which most patients do not really care). - It is important to be able to ask discriminating, delineating questions about particular symptoms to verify their actual nature and give enough information to support the process of reaching a diagnosis; however, timing is everything. Get down a record of each of the major symptoms in the order that they are presented to you by the patient. Then go back to this overall picture and break down any aspects of the history that you need to from there. This is a much better way of doing things than interrupting (and probably losing for ever) the patient’s initial narrative.
- Listening does not just involve using your ears. Also use facial expression, body language and verbal fluency to help understand what is really troubling someone and to suggest other areas in which the history might need to proceed. This is very useful where there is a psychological origin for physical symptoms, of which the patient may be unconscious, but you could get at if you noticed that talking about a certain aspect of their story makes them uncomfortable or hesitant. Remember that speech is not the only means of communicating, especially where someone has a poor command of the language in which you are taking the history, or has hearing impairment. Make full use of communication aids such as translators, sign-language interpreters, picture boards, and drawings done by the patient showing where the pain is, when this is a more appropriate form of discourse.
- 6551 WK 3 SOAP assignment states that, some patients do not come readily prepared with a narrative of their illness and, in this situation, it is unavoidable to use questioning and clarification of details to ‘draw out’ the history. However, if your prompting sparks off a narrative then try to hear it out if it seems to be relevant. Try to avoid interrupting if at all possible.
Reference
Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.
Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)
Chapter 7, “Care of the Woman with Reproductive Health Problems”
“Care of the Woman with Dysmenorrhea” (pp. 366–368)
“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)
