Army Soap Note

A: (assessment) – Your interpretation of the patients condition. P: (plan) – Includes the following: 1. Medical treatment: includes use of meds, use of bandages, etc. 2. Additional diagnostics: which if any test which still might be needed. X-ray MRI ect.. 3. Special instructions, handouts, use of medications, side effects, etc. 4. Return to clinic: when and under what circumstances to return. Components of the SOAP note. . Medical History – Which gives you an idea of the patients problem before you start the physical exam of the patient. a. Patient data b. chief complaint 1. This is the reason for the patients visit. 2. Use direct quotes from patient. 3. Avoid using medical terms. c. Observations begin as soon as the patient walks through the door. d. Open ended questions will help you to get more complete and accurate information. e. Provider obstacles which are your attitude towards the individual or pre diagnosis of sick call ranger may prevent you from makin g an accurate judgment. . History of present illness/injury (HPI) f. Duration: when the illness/injury started. g. Type of pain: use the patients words to describe the type of pain. h. Location: have the patient explain, then have them point it out. i. : what makes it better or worse and is it constant or does it vary in intensity. j. Pain in different positions: does the pain vary with the change of the patients position. k. Medications/allergies: note any medications whether over the counter or not. Do the medications relate to the problem? Take note of the patients allergies. l. Supplements: note any supplements the patient is taking along with vitamins so you are aware of the possible interactions with the medication that may be given to the patient. m. Pertinent facts: facts which lead you to your diagnosis. Usually consist of classical signs and/or symptoms. I have found that the best way to get a person’s medical history is to using the SAMPLE and OPQRST. It’s a fast and easy way to recall the information that you need to provide to the PA or NCOIC. S: Symptoms A: Allergies M: Medicine taken P: Past history of similar events L: Last meal E: Events leading up to illness or injury O: Onset – What caused the illness or injury, or what were you doing at the time P: Provocation/Position – what brought symptoms on, where is pain located. Q: Quality – sharp, dull, crushing etc†¦ R: Radiation – does pain travel S: Severity/Symptoms Associated with or on a scale of 1 to 10, what other symptoms occur T: Timing/Triggers – occasional, constant, intermittent, only when I do this. Lastly you need to provide a name(first, last and middle initial) phone number, date of birth, FULL social security number, sex, and rank/grade. All this information is provided in order to file the note into the patients medical records. It can also be used to contact the patient regarding an appointment or information we may further need to assist the patient in his medical needs. All notes must be signed by the individual that screened the patient. There are 2 reason for this one is to insure that nothing is added to the note, this protects both yourself and the patient. It also allows the PA or NCOIC to speak with the individual that screened the patient for additional information regarding the patient or having them correct a deficiency with the note itself before being placed in the patients medical history. Signing under the last portion of the note lets people know that the note has ended however do not mark any open space out, the PA may want to add additional information which he will then stamp verifying that he was the one who in fact added the information. Spc Singleton 68W10 Army Soap Note A: (assessment) – Your interpretation of the patients condition. P: (plan) – Includes the following: 1. Medical treatment: includes use of meds, use of bandages, etc. 2. Additional diagnostics: which if any test which still might be needed. X-ray MRI ect.. 3. Special instructions, handouts, use of medications, side effects, etc. 4. Return to clinic: when and under what circumstances to return. Components of the SOAP note. . Medical History – Which gives you an idea of the patients problem before you start the physical exam of the patient. a. Patient data b. chief complaint 1. This is the reason for the patients visit. 2. Use direct quotes from patient. 3. Avoid using medical terms. c. Observations begin as soon as the patient walks through the door. d. Open ended questions will help you to get more complete and accurate information. e. Provider obstacles which are your attitude towards the individual or pre diagnosis of sick call ranger may prevent you from makin g an accurate judgment. . History of present illness/injury (HPI) f. Duration: when the illness/injury started. g. Type of pain: use the patients words to describe the type of pain. h. Location: have the patient explain, then have them point it out. i. : what makes it better or worse and is it constant or does it vary in intensity. j. Pain in different positions: does the pain vary with the change of the patients position. k. Medications/allergies: note any medications whether over the counter or not. Do the medications relate to the problem? Take note of the patients allergies. l. Supplements: note any supplements the patient is taking along with vitamins so you are aware of the possible interactions with the medication that may be given to the patient. m. Pertinent facts: facts which lead you to your diagnosis. Usually consist of classical signs and/or symptoms. I have found that the best way to get a person’s medical history is to using the SAMPLE and OPQRST. It’s a fast and easy way to recall the information that you need to provide to the PA or NCOIC. S: Symptoms A: Allergies M: Medicine taken P: Past history of similar events L: Last meal E: Events leading up to illness or injury O: Onset – What caused the illness or injury, or what were you doing at the time P: Provocation/Position – what brought symptoms on, where is pain located. Q: Quality – sharp, dull, crushing etc†¦ R: Radiation – does pain travel S: Severity/Symptoms Associated with or on a scale of 1 to 10, what other symptoms occur T: Timing/Triggers – occasional, constant, intermittent, only when I do this. Lastly you need to provide a name(first, last and middle initial) phone number, date of birth, FULL social security number, sex, and rank/grade. All this information is provided in order to file the note into the patients medical records. It can also be used to contact the patient regarding an appointment or information we may further need to assist the patient in his medical needs. All notes must be signed by the individual that screened the patient. There are 2 reason for this one is to insure that nothing is added to the note, this protects both yourself and the patient. It also allows the PA or NCOIC to speak with the individual that screened the patient for additional information regarding the patient or having them correct a deficiency with the note itself before being placed in the patients medical history. Signing under the last portion of the note lets people know that the note has ended however do not mark any open space out, the PA may want to add additional information which he will then stamp verifying that he was the one who in fact added the information. Spc Singleton 68W10

Literature review (Effectiveness of Web-based Distance Education) Essay

Literature review (Effectiveness of Web-based Distance Education) - Essay Example That is why the web-based distance education has been the first choice to many learners. As web based learning becomes more popular in the modern world, there are issues which must be able to be looked at in order to make sure that learners who use this system are able to learn just as effectively and efficiently as those using he traditional method (Roberts & McInnerney, 2007). Formal education has a very long history and a big part of this history is geared towards the traditional system of learning. In this regard, most of the theories and models of learning which have been developed have been developed around the traditional modes of learning and there is little theory to support the new and upcoming models such as web based learning. In this regard, it is necessary for there to be an understanding of how the web based and other virtual learning systems can be used to deliver knowledge to learners without compromising on the integrity of the education which the learners received. Without doing this, it will be hard to use such learning environments to able to help t he students as well as the tutors to be able to use the system to deliver kind of education required of them. At the same time, it will be necessary to recognize that learning environments are changing and that there is a need to make sure that there are systems as well as theories and models to support the new modes of learning and teaching. The issue of web based learning, or learning as it is referred by some people, is one which has been a major debate. Debate about web based learning or eLearning start from issues as trivial as what can be said to constitute eLearning and how the term should be spelled. However, there are more serious issues which must be looked at. These issues revolve around the credibility and the effectiveness as well as

Critical reception of William Hogarth in the nineteenth century Essay

Critical reception of William Hogarth in the nineteenth century - Essay Example According to Gray (140), his contemporaries compared Fedotov who is a Russian artist with Hogarth; for instance, Druzhinin describing Fedotov drawing of a woman leading her drunken husband through the streets claims that Hogarth would not refuse a subject rich in dramatic and satirical potential. Although the two artists use romantic themes of the misunderstood, impoverished artist and enforce pathos of the situation with abundant symbolic detail. Druzhinin later lamented the loss of a man who in his opinion believes could have been Russia’s Hogarth because Fedotov had the potential to go beyond the achievements of the famous English artist. Other commentators of Fedotov did not encourage him to emulate Hogarth; for instance, Bryullov advised him not to be attracted by complexities of Hogarth but encouraged Fedotov to follow nature (Gray 140). Until 18th century, continental Europe set the artistic agenda with the first artist using true English style and sensibility being William Hogarth who exposed vice and corruption in the 18th century London (Else 69). While Hogarth satirized the society other artists were busy showing the best light of the society in the 18th century. Through the nineteenth and twentieth century there were various views; however in the Victorian time, Hogarth emerged as a popular figure as well as honest and patriotic Englishman (Bindman and William 13). Hogarth issues regarding artistic origins as well as background emerged in early 1780s with publication of the fourth volume of Horace Walpole’s Anecdotes of painting in England that dealt with contemporaries including Hogarth. Considering the role of Hogarth’s widow following his death, there is an indication of moral conversion in the widow through suppression of indecent print and she engaged with Rev.Dr Trusler in producing a [popu lar volume known as Hogarth Moralized in 1768.