SOAP for Nursing, Essay Example

The sole purpose of a SOAP note in the medical field is for the standardization of medical evaluation entries. SOAP means Subjective, Objective, Assessment and finally Plan. Subjective data finds out how the patient is feeling; pain, tension or fatigue. Objective data are the results of the tests carried out on the patient. Assessment is where a nurse uses both the objective and subjective data to personally assess what is wrong with the patient, as reported by (Weed 1976). Plan is the action a nurse takes in treating the patient to make things better. All SOAP include; the date and also the purpose of the patient’s visit, complaints and symptoms, current physical exam, results from tests and plan to treat the patient.

Mrs. Reynolds visited the clinic on a Monday morning. The nurses measured her weight, temperature, pulse, visual acuity and blood pressure before they asked her questions. She complained of excruciating pain around her neck. She could not hold her head up for a long time or turn her head sideways. This can be a number of disorders from cervicocranial syndrome to cervicalgia as (Seffinger, Friedman, Johnston 1995) suggest.

Thorough tests were done to find the cause of the pain and the nurse later found out that she was suffering from cervicalgia. This was after thorough assessment of the results and her constant pain. The pain in the neck muscles and the difficulty to look side ways meant that the neck was under pressure for supporting the head for such a long time and it was tensed.

The nurse later planned to use with myofascial release and also muscle energy to treat her condition. After two weeks of follow-up the patient had recovered and she could turn her head easily. The purpose of SOAP is to learn how to listen to patients, diagnose a disease, assess the disease and later treat it using the most efficient drugs or methods, as (Owens 1998) reports.

References

Owens, D.K. (1998). Use of medical informatics to implement and develop clinical practice guidelines. California: West J Med.

Seffinger. M.A, Friedman. H.D. & Johnston, W.L. (1995). Standardization of the hospital record for osteopathic structural examination: recording of musculoskeletal findings and somatic dysfunction diagnosis. NY: Osteopath Assoc.

Weed, L.L. (1976). Implementing the Problem-Oriented Record. 2nd ed. Seattle: Wash Inc.

Weed, L.L. (1969). The Problem-Oriented Medical Record as a Basic Tool. Cleveland, Ohio: The Press of Case Western Reserve University.