Information for Soap Notes Essay Example for Free

Information for Soap Notes Essay Associate Level Material Case Study Information for SOAP Notes Read the following three patient visits. Rewrite the information using correct medical terminology. The visits below are written in layman’s terms and do not use the correct medical terminology. Re-write the information in medical terms for the charts. You must determine where the information is to be placed in the SOAP note. Patient One – Chapter Six 22-year-old African American female 140/60 BP 99 F Pulse is 38 Breathing is 22 per minute Patient states she is not on any medicine at the time Patient states her reason for the visit is she is having severe back pain for 5 days now Past has been told she has sickle cell anemia Physician tells patient they are going to draw blood and give her IV with fluids. Physician states the IV will contain something for the pain Blood work showed white blood cells 4300, hemoglobin 13. 1 g/dL, hematocrit 39. 9%, platelets 162,000, segs 65. 9, lymphs 27, monos 3. 4 Physician observes patient is alert Physician finds that head, ears, eyes, nose, and throat are okay Physician determines the patient is having a sickle cell crisis Physician finds that the patient has numbness in hands and feet Patient states she just has not been feeling well lately She reports â€Å"I do not test my levels daily with that machine it hurts so I just base my levels on how well I feel† Physician observes that the patient has some discoloration of her skin Physician sees that the head, eyes, ears, nose and throat are okay Physician hears that the heart sounds good, nothing sounds off Physician wants patient to come to the office in 1 month Physician tells patient to start using the machine to test her blood and record the results and bring with her to next visit