The Soap Record

Descripción

Lab Skills: Obtain a new patient history and accurately record information
S Sousa
Fichas por S Sousa, actualizado hace más de 1 año
S Sousa
Creado por S Sousa hace alrededor de 5 años
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Resumen del Recurso

Pregunta Respuesta
SOAP SOAP is an acronym for Subjective, Objective, Assessment, Plan
1. Subjective Section Owner's observations, Patient's history
2. Objective Section Veterinary professional's observation
3. Assessment Section Veterinarian's Summary of patient's problem(s)
4. Plan Section Veterinarian's plan for treatment of patient's problem
Patient Signalment IDENTIFY your patient: Patient Name, Species, Breed, Age or D.O.B., Sex & Reproductive Status, Color & Markings*
How is patient NAME listed/noted? “Pet’s Name” in quotations, followed by the owner’s last name
What is appropriate to list under the SPECIES category? Canine, K9, or Dog Feline or Fel
How should an animals BREED be noted? Universally accepted abbreviations are OK to use (Chi, Yorkie, Lab, Rott, etc) For mutts, write predominant breed name followed by “mix” or a capital “X”
How should an animal's sex and reproductive status be noted? Intact male can be written as “M” Neutered male can be written as “M/N” Intact female can be written as “F” Spayed female can be written as “F/S”
What is important to know when listing the AGE of a patient? Never write just a number. Always age along with weeks/months/years
How should an patient's COLOR and MARKINGS be listed? Use universal colors that are understood by veterinary personnel (brown – tan, chocolate, red, liver, etc)
Patient History This section is reserved for the client’s subjective observations, concerns, and requests (Subjective Section)
Patient history should cover these items Chief complaint (FIRST. ALWAYS.) Any C/S/V/D Appetite, thirst, & activity level Bowels and urine output Diet Medications or supplements Vaccine history Medical history Environment & risks
Chief Complaint The “reason for visit” What the patient is experiencing as a result of an undetermined problem.
Chief Complaint: What? What happened? (and did someone see it happen?) What symptoms is the patient experiencing?
Chief Complaint: Where Where on the body? (Which part of the body is affected) Where did the incident occur?
Chief Complaint: When? When did this happen /when did this start? When do symptoms occur? (After playing, eating, drinking, etc…)
Chief Complaint: How? How long has this been going on? (and has it gotten better, worse, or stayed the same?) How often does this happen? How have the patient’s normal activities been affected?
C/S/V/D coughing, sneezing, vomiting, diarrhea
Vaccination history & status Are Vx UTD?
Medical history Past or current diseases / conditions? Any recent Sx?
Medications & Supplements What is the patient taking? When was it last given?
Diet & Feeding Schedule What brand / type of food? How much, how often?
Environment % indoor / % outdoor Other animals in the home
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