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The Ultimate Guide to Writing a SOAP Note for Asthma
Asthma, a chronic respiratory condition affecting millions, demands meticulous documentation for effective management and treatment. For healthcare professionals, accurately capturing patient information is crucial. This comprehensive guide provides a detailed walkthrough on crafting a thorough and effective SOAP note asthma. We'll cover each section – Subjective, Objective, Assessment, and Plan – with examples and best practices to ensure your documentation is not only compliant but also facilitates optimal patient care. This guide will equip you with the knowledge to write clear, concise, and impactful SOAP notes for your asthmatic patients, improving both your workflow and patient outcomes.
Understanding the SOAP Note Format
Before diving into asthma-specific details, let's refresh our understanding of the SOAP note structure:
S – Subjective: This section focuses on the patient's self-reported symptoms, history, and concerns. It's what the patient tells you.
O – Objective: This section documents measurable and observable findings from your examination, tests, and other objective data.
A – Assessment: This is your professional interpretation of the subjective and objective data, including your diagnosis and identification of potential problems.
P – Plan: This outlines your proposed treatment plan, including medications, referrals, and follow-up appointments.
Crafting the Subjective (S) Section of Your SOAP Note for Asthma
This section forms the foundation of your asthma SOAP note. Begin by documenting the patient's chief complaint. For example: "Patient presents with worsening shortness of breath and wheezing." Then, delve deeper using the following prompts:
Symptom History: Record the onset, duration, frequency, and severity of symptoms. For example: "Wheezing started three days ago, initially mild but progressively worsening over the past 24 hours. Patient reports shortness of breath with exertion."
Symptom Characteristics: Describe the nature of the symptoms. Is the cough productive or non-productive? Is the wheezing continuous or intermittent? What triggers the symptoms (e.g., exercise, allergens, infections)?
Past Medical History: Note any previous asthma attacks, hospitalizations, or emergency room visits related to asthma. Include details about previous treatments and their effectiveness.
Medication History: List all current medications, including inhalers, controllers, and rescue medications. Note dosages and frequency of use.
Allergies: Document any known allergies, especially medication allergies.
Social History: Consider factors like smoking, exposure to environmental irritants, pets, and occupational hazards. These can significantly influence asthma management.
The Objective (O) Section: Measurable Data for Your Asthma SOAP Note
The objective section requires precise and quantifiable data. Include the following:
Vital Signs: Record blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation (SpO2). Note any abnormalities. A low SpO2 reading is particularly important in assessing asthma severity.
Physical Exam: Document your findings from the respiratory exam, including auscultation (wheezing, rales, rhonchi), percussion (hyperresonance), and palpation (chest expansion). Note any signs of respiratory distress, such as use of accessory muscles or nasal flaring.
Peak Expiratory Flow (PEF): If using a peak flow meter, record the patient's PEF readings. This objective measurement helps assess lung function and track disease progression.
Laboratory Results: Include any relevant lab results, such as complete blood count (CBC) or allergy testing.
The Assessment (A) Section: Diagnosing and Interpreting the Data
In the assessment section, synthesize the subjective and objective findings to arrive at a diagnosis. This might include:
Asthma Severity: Classify the asthma severity based on the patient's symptoms, PEF readings, and frequency of exacerbations (mild intermittent, mild persistent, moderate persistent, severe persistent).
Exacerbation Status: Indicate whether the patient is experiencing an acute exacerbation, stable asthma, or another relevant condition.
Contributing Factors: Identify any factors that might be contributing to the patient's symptoms, such as infections, allergens, or medication non-compliance.
Differential Diagnoses: Briefly list any other conditions that might explain the patient's symptoms.
The Plan (P) Section: Developing a Treatment Strategy
This section outlines your treatment plan, incorporating both short-term and long-term strategies:
Medication Adjustments: Specify any changes to the patient's current medication regimen, including dosage increases, addition of new medications (e.g., corticosteroids), or changes in inhaler technique.
Short-Term Interventions: Detail immediate interventions for acute exacerbations, such as bronchodilators, corticosteroids, or oxygen therapy.
Long-Term Management: Outline the long-term asthma management plan, including regular follow-up appointments, allergy testing, and education on asthma triggers and self-management techniques.
Referral: If necessary, indicate any referrals to specialists (e.g., pulmonologist, allergist).
Patient Education: Document any patient education provided, including instructions on medication use, inhaler technique, and self-management strategies.
Conclusion
Writing a comprehensive and effective SOAP note asthma requires attention to detail and a clear understanding of the disease process. By following the guidelines outlined in this post, healthcare professionals can ensure accurate documentation that supports optimal patient care and contributes to improved outcomes. Consistent and thorough documentation plays a vital role in managing asthma effectively and minimizing the risk of serious complications.
FAQs
1. What if my patient doesn't remember their medication details? In such cases, document the patient's inability to recall and indicate a need to obtain the information from a pharmacy or other reliable source.
2. How frequently should I write a SOAP note for an asthma patient? Frequency depends on the patient's stability. Patients with well-controlled asthma might only require notes during routine check-ups, while those with frequent exacerbations may require more frequent documentation.
3. Can I use abbreviations in my SOAP note? Use only standard medical abbreviations to maintain clarity and avoid potential misinterpretations.
4. What should I do if I suspect an adverse drug reaction to asthma medication? Immediately document your suspicion and any related symptoms. Contact the prescribing physician or relevant authority, and take appropriate action based on institutional guidelines.
5. How can I improve my SOAP note writing skills? Review existing notes, seek feedback from colleagues, and utilize templates or checklists to maintain consistency and thoroughness. Consider attending continuing education courses focused on medical record keeping.
| soap note asthma: Foundations for Community Health Workers Tim Berthold, Alma Avila, Jennifer Miller, 2009-08-13 Foundations for Community Health Workers Foundations for Community Health Workers is a training resource for client- and community-centered public health practitioners, with an emphasis on promoting health equality. Based on City College of San Francisco's CHW Certificate Program, it begins with an overview of the historic and political context informing the practice of community health workers. The second section of the book addresses core competencies for working with individual clients, such as behavior change counseling and case management, and practitioner development topics such as ethics, stress management, and conflict resolution. The book's final section covers skills for practice at the group and community levels, such as conducting health outreach and facilitating community organizing and advocacy. Praise for Foundations for Community Health Workers This book is the first of its kind: a manual of core competencies and curricula for training community health workers. Covering topics from health inequalities to patient-centered counseling, this book is a tremendous resource for both scholars of and practitioners in the field of community-based medicine. It also marks a great step forward in any setting, rich or poor, in which it is imperative to reduce health disparities and promote genuine health and well-being. Paul E. Farmer, MD., PhD, Maude and Lillian Presley Professor of Social Medicine in the Department of Global Health and Social Medicine at Harvard Medical School; founding director, Partners In Health. This book is based on the contributions of experienced CHWs and advocates of the field. I am confident that it will serve as an inspiration for many CHW training programs. Yvonne Lacey, CHW, former coordinator, Black Infant Health Program, City of Berkeley Health Department; former chair, CHW Special Interest Group for the APHA. This book masterfully integrates the knowledge, skills, and abilities required of a CHW through storytelling and real life case examples. This simple and elegant approach brings to life the intricacies of the work and espouses the spirit of the role that is so critical to eliminating disparities a true model educational approach to emulate. Gayle Tang, MSN, RN., director, National Linguistic and Cultural Programs, National Diversity, Kaiser Permanente Finally, we have a competency-based textbook for community health worker education well informed by seasoned CHWs themselves as well as expert contributors. Donald E. Proulx, CHW National Education Collaborative, University of Arizona |
| soap note asthma: Laboratory Manual of Pharmacotherapeutics Dr. Remeth J. Dias, Dr. Kuldeep U. Bansod, Dr. Prashant D. Aragade, Mr. Sushant Sudhir Pande, 2023-09-29 We are very pleased to put forth the revised edition of 'Laboratory Manual of Pharmacotherapeutics'. We have incorporated all the suggestions, modified it to make it easier, student friendly and relevant in terms of achieving curriculum outcome. We are very much thankful to all the learned teachers who have given their feedback whole-heartedly. We have even incorporated the changes in this manual based on the feedback given by the teachers from all the institutes. Now, we believe that the manual has been fulfilling the aspirations of Pharmacotherapeutics' teachers and students too. This manual is prepared as per PCI Education Regulations, 2020 for Diploma Course in Pharmacy. The methods of all the experiments are reviewed and added from the recent research papers, so that the advancement in the methods or apparatus can be addressed. This manual is designed for 'outcome-based education' and each experiment is arranged in a uniform way such as practical significance, practical outcomes (PrOs) and its mapping with course outcomes, minimum theoretical background, resources used, procedure, precautions, observations, result, conclusion, references, and related questions. Moreover, assessment scheme is also given to help the student and teacher to know what to be assessed. Every experiment has the component of the activity or role play included so that the students will be able to interact with patients and give them counselling tips on the proper care to be taken in chronic diseases. In addition, the questions are given at the end of experiments to increase the knowledge of students, which would be helpful for them when they will go for higher studies. Hope this manual will help the students to learn the concept, principles and perform activities and role play counselling the public about diseases and medication. We wish you all the best!!! |
| soap note asthma: SOAP for Family Medicine Daniel Maldonado, 2018-08-14 Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar SOAP note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, Pas, and NPs during the Family Medicine rotation. |
| soap note asthma: Clinical Manifestations & Assessment of Respiratory Disease E-Book Terry Des Jardins, George G. Burton, 2019-01-06 - NEW! Respiratory Insufficiency in the Patient with Neuro-Respiratory Disease chapter outlines the respiratory therapist's role in regard to these protocols. - NEW! Illustrations in designated chapters ensures you have a visual representation of disease processes, and the latest assessment and treatment procedures. |
| soap note asthma: SOAP for Emergency Medicine Michael C. Bond, 2005 SOAP for Emergency Medicine features 85 clinical problems with each case presented in an easy to read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. The SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar SOAP note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem, not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a must have to keep in their white coat pockets for wards and clinics. |
| soap note asthma: SOAP for Internal Medicine Peter S. Uzelac, Richard W. Moon, 2005 SOAP for Internal Medicine features 75 clinical problems with each case presented in an easy-to-read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. The SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar SOAP note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem, not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a must-have to keep in their white coat pockets for wards and clinics. |
| soap note asthma: Clinical Simulations for the Advanced Practice Nurse Celeste M. Alfes, DNP, MSN, RN, CNE, CHSE-A, FAAN, Elizabeth Zimmermann, DNP, MSN, RN, CHSE, 2020-03-19 Provides high-quality, comprehensive simulation scenarios for APRNs This invaluable resource is the first simulation guide designed specifically to support the training and evaluation of advanced practice nursing students, novice nurse practitioners, and advanced practice nurses transitioning to new fields. This book provides a method and foundation to transform graduate nursing education to competency-based clinical evaluation, empowering programs with standardized templates and interprofessional education options for each scenario to advance graduate simulation education and research. This comprehensive guide delivers more than 50 comprehensive simulation scenarios, written by experienced APRNs, faculty, and simulation specialists. Scenarios are arranged by APRN specialty with applications for students, faculty, standardized patients, staff development, and simulation staff who prepare the advanced practice nurse and their interprofessional team for clinical practice. Not only is this text easy for faculty to use and implement, it also includes several levels of application and offers strategies for adapting scenarios to an interprofessional setting. Each simulation is structured into a consistent template for ease of use, which includes a description, objectives, equipment needed, pre-briefing, debriefing, and interprofessional considerations. Additionally, each scenario includes a one-page download designed for the Simulation Team focusing on “what happens” in a particular scenario. These comprehensive simulations encompass a wide variety of physical health and mental health scenarios across the lifespan as well as telehealth, critical care transport, and retail scenarios. Three detailed sections dedicated to APRN students, faculty, and simulation staff provide timely topics and sound advice from recent graduates, faculty experts, and leaders in the simulation field. The section for students provides anticipatory guidance for novice practitioners on how best to prepare for formative and summative evaluations, standardized patient patientinteractions, high-stakes simulation testing, and interprofessional experiences. The section for faculty provides practical information on how to design engaging simulation experiences for the APRN, and suggestions on mapping the various modes of simulation experiences to various levels and competencies. A detailed section directed to the simulations team covers operations and management of the environment, personnel, equipment, and resources. Key Features: Provides 10 Objective Structured Clinical Examination (OSCE) standard scenarios for general advanced practice assessment Contains more than 50 comprehensive simulation scenarios, arranged by APRN specialty for formative, summative, and high-stakes testing and competency evaluations Consistent with INACSL and SSH Simulation Standards of Best Practice and NLN Simulation Theory by Pamela Jeffries Maps simulation experiences to APRN learner levels and AACN competencies Includes separate sections tailored towards APRN students, APRN faculty and staff development, and the simulation operational team Delineates and provides hyperlinks for suggested learner preparation and the most up-to-date references to support each scenario |
| soap note asthma: Integrative Medicine David Rakel, 2007-01-01 Drawing on solid scientific evidence as well as extensive first-hand experience, this manual provides the practical information you need to safely and effectively integrate complementary and alternative treatment modalities into your practice. It explains how alternative therapies can help you fight diseases that do not respond readily to traditional treatments... presents integrative treatments for a full range of diseases and conditions, including autism, stroke, chronic fatigue syndrome, and various forms of cancer...explores how to advise patients on health maintenance and wellness...and offers advice on topics such as meditation, diet, and exercises for back pain. 24 new chapters, a new organization, make this landmark reference more useful than ever. Provides dosages and precautions to help you avoid potential complications.Delivers therapy-based pearls to enhance your patient care.Facilitates patient education with helpful handouts. Offers helpful icons that highlight the level and quality of evidence for each specific modality.Includes bonus PDA software that lets you load all of the therapeutic review sections onto your handheld device.Presents a new organization, with numerous section headings and subheadings, for greater ease of reference.Provides additional clinical practice and business considerations for incorporating integrative medicine into clinical practice. |
| soap note asthma: Family Nurse Practitioner Certification Intensive Review Maria T. Codina Leik, 2013-08-12 Print+CourseSmart |
| soap note asthma: SOAP for Obstetrics and Gynecology Peter S. Uzelac, 2005 SOAP for Obstetrics and Gynecology features over 60 clinical problems with each case presented in an easy-to-read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. The SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar SOAP note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem, not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a must-have to keep in their white coat pockets for wards and clinics. |
| soap note asthma: SOAP for the Rotations Peter S. Uzelac, 2019-07-11 Ideal for medical students, PAs and NPs, this pocket-sized quick reference helps students hone the clinical reasoning and documentation skills needed for effective practice in internal medicine, pediatrics, OB/GYN, surgery, emergency medicine, and psychiatry. This updated edition offers step-by-step guidance on how to properly document patient care as it addresses the most common clinical problems encountered on the wards and clinics. Emphasizing the patient’s clinical problem, not the diagnosis, the book’s at-a-glance, two-page layout uses the familiar SOAP note format. |
| soap note asthma: Pocket Book of Hospital Care for Children World Health Organization, 2013 The Pocket Book is for use by doctors nurses and other health workers who are responsible for the care of young children at the first level referral hospitals. This second edition is based on evidence from several WHO updated and published clinical guidelines. It is for use in both inpatient and outpatient care in small hospitals with basic laboratory facilities and essential medicines. In some settings these guidelines can be used in any facilities where sick children are admitted for inpatient care. The Pocket Book is one of a series of documents and tools that support the Integrated Managem. |
| soap note asthma: Health Information Technology - E-Book Nadinia A. Davis, Melissa LaCour, 2014-03-27 Reflecting emerging trends in today’s health information management, Health Information Technology, 3rd Edition covers everything from electronic health records and collecting healthcare data to coding and compliance. It prepares you for a role as a Registered Health Information Technician, one in which you not only file and keep accurate records but serve as a healthcare analyst who translates data into useful, quality information that can control costs and further research. This edition includes new full-color illustrations and easy access to definitions of daunting terms and acronyms. Written by expert educators Nadinia Davis and Melissa LaCour, this book also offers invaluable preparation for the HIT certification exam. Workbook exercises in the book help you review and apply key concepts immediately after you’ve studied the core topics. Clear writing style and easy reading level makes reading and studying more time-efficient. Chapter learning objectives help you prepare for the credentialing exam by corresponding to the American Health Information Management Association's (AHIMA) domains and subdomains of the Health Information Technology (HIT) curriculum. A separate Confidentiality and Compliance chapter covers HIPAA privacy regulations. Job descriptions in every chapter offer a broad view of the field and show career options following graduation and certification. Student resources on the Evolve companion website include sample paper forms and provide an interactive learning environment. NEW! Full-color illustrations aid comprehension and help you visualize concepts. UPDATED information accurately depicts today’s technology, including records processing in the EHR and hybrid environments, digital storage concerns, information systems implementation, and security issues, including HITECH’s impact on HIPAA regulations. NEW! Glossary terms and definitions plus acronyms/abbreviations in the margins provide easy access to definitions of key vocabulary and confusing abbreviations. NEW! Go Tos in the margins cross-reference the textbook by specific chapters. NEW Coding boxes in the margins provide examples of common code sets. Over 100 NEW vocabulary terms and definitions ensure that the material is current and comprehensive. NEW Patient Care Perspective and Career Tips at the end of chapters include examples of important HIM activities in patient care and customer service. |
| soap note asthma: Textbook of Therapeutics Richard A. Helms, David J. Quan, 2006 The contributors to this volume deliver information on latest drug treatments and therapeutic approaches for a wide range of diseases and conditions. Coverage includes discussion of racial, ethnic, and gender differences in response to drugs and to biotechnical, pediatric and neonatal therapies. |
| soap note asthma: Fundamental Skills for Patient Care in Pharmacy Practice Colleen Doherty Lauster, Sneha Baxi Srivastava, 2013-03-25 Fundamental Skills for Patient Care in Pharmacy Practice enables students and new pharmacists to master the skills associated with clinical care in either the inpatient or outpatient setting. In accessible steps, this valuable resource provides the tools for gaining medication histories from patients and counseling them on the most effective and safe manner to take medications. Each chapter explores the background and practice of a critical skill, tools that aid in its development and mastery, and tips for success. Students and pharmacists will come away with the knowledge to identify drug-related problems and formulate plans for solutions to these problems. Fundamental Skills for Patient Care in Pharmacy Practice prepares future pharmacists to communicate effectively in verbal and written formats with health professionals and special patient populations as they prepare and present SOAP notes, patient cases, and discharge counseling. |
| soap note asthma: Lifestyle Modifications in Pharmacotherapy Thomas L. Lenz, 2008 This innovative text equips pharmacists and pharmacy students with the skills to assist patients in managing existing conditions and controlling the development of preventable disorders. The text demonstrates how important lifestyle modification strategies—including nutrition, physical activity, weight control, and smoking cessation—can be used in a pharmacy setting to improve patients' well-being. Case studies show how lifestyle modifications can positively impact patients with chronic diseases. Chapters explain how lifestyle modification strategies might be different for children, adolescents, older adults, women, and minorities. The book includes detailed instructions for writing wellness plans for patients who have, or are at risk for, certain chronic diseases. |
| soap note asthma: Clinical Manifestations and Assessment of Respiratory Disease Terry R. Des Jardins, George G. Burton, 2006 The new edition of this popular text has been extensively revised to reflect the latest changes in the field. The introductory chapters address the fundamental skills and protocols necessary for clinical assessment. Each disease is presented in relation to one of six clinical scenarios: atelectasis, consolidation, increased alveolar-capillary membrane thickness, bronchospasm, excessive bronchial secretions, and distal airway and alveolar weakening. Students are provided with an illustration of the major alterations of the lungs, the etiology of the disease, an overview of clinical manifestations, a discussion of management, and a series of self-assessment questions. Emphasis on clinical scenarios that allows the student to better understand the diseases. It shows them why they are seeing what they are seeing and why certain treatment modalities are being used. Focus on assessment and therapist-driven protocols (TDPs) so students can incorporate this into their care of patients. Full-color insert that aids the reader in visualizing and understanding the pathophysiology of the diseases. Clinical Manifestation Overview boxes that enable students to easily refer back to the most important information about the pathophysiologic mechanisms for each disorder of the lung and confirm that they have learned the key information. Case studies that aid the student and the instructor in applying the fundamental information to the assessment and treatment of respiratory patients. Twelve easily accessible appendices featuring commonly needed information such as abbreviations, equations, medications, hemodynamic measurements, and more. Two color design that engages the reader by highlighting different elements of the text and details within the line drawings. Access to the Evolve Learning System that includes additional case studies, a PowerPoint presentation of lecture material, a test bank, an image collection, and Weblinks |
| soap note asthma: Clinical Case Studies for the Family Nurse Practitioner Leslie Neal-Boylan, 2011-11-28 Clinical Case Studies for the Family Nurse Practitioner is a key resource for advanced practice nurses and graduate students seeking to test their skills in assessing, diagnosing, and managing cases in family and primary care. Composed of more than 70 cases ranging from common to unique, the book compiles years of experience from experts in the field. It is organized chronologically, presenting cases from neonatal to geriatric care in a standard approach built on the SOAP format. This includes differential diagnosis and a series of critical thinking questions ideal for self-assessment or classroom use. |
| soap note asthma: SOAP for Pediatrics Michael A. Polisky, Breck Nichols, 2005 SOAP for Pediatrics features over 70 clinical problems with each case presented in an easy to read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. Blackwell's new SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar SOAP note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a must have to keep in their white coat pockets for wards and clinics. |
| soap note asthma: Writing Patient/Client Notes Ginge Kettenbach, Sarah Lynn Schlomer, Jill Fitzgerald, 2016-05-11 Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model. |
| soap note asthma: Document Smart Theresa Capriotti, 2019-06-26 Feeling unsure about documenting patient care? Learn to document with skill and ease, with the freshly updated Document Smart, 4th Edition. This unique, easy-to-use resource is a must-have for every student and new nurse, offering more than 300 alpha-organized topics that demonstrate the latest nursing, medical and government best practices for documenting a wide variety of patient conditions and scenarios. Whether you are assessing data, creating effective patient goals, choosing optimal interventions or evaluating treatment, this is your road map to documentation confidence and clarity. |
| soap note asthma: Caring for People who Sniff Petrol Or Other Volatile Substances National Health and Medical Research Council (Australia), 2011 These guidelines provide recommendations that outline the critical aspects of infection prevention and control. The recommendations were developed using the best available evidence and consensus methods by the Infection Control Steering Committee. They have been prioritised as key areas to prevent and control infection in a healthcare facility. It is recognised that the level of risk may differ according to the different types of facility and therefore some recommendations should be justified by risk assessment. When implementing these recommendations all healthcare facilities need to consider the risk of transmission of infection and implement according to their specific setting and circumstances. |
| soap note asthma: Guide to Clinical Documentation Debra D Sullivan, 2018-07-25 Understand the when, why, and how! Here’s your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward ‘how-to’ approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand. |
| soap note asthma: Guide to Clinical Documentation Debra Sullivan, 2011-12-22 Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions. |
| soap note asthma: SOAP for Family Medicine Daniel Maldonado, Cynthia Zuniga, 2023-10-11 Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar SOAP note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, PAs, and NPs during the Family Medicine rotation. The Introduction offers templates, tips, and guidelines for writing SOAP notes. A portable, pocket-sized format with at-a-glance, two-page layouts makes practical information quickly accessible. The SOAP approach helps students figure out where to start, while improving communication between physicians and ensuring accurate documentation. |
| soap note asthma: Notes on New Remedies , 1891 |
| soap note asthma: Asthma Richard F. Lockey, Dennis K. Ledford, 2014 Diagnosing asthma requires knowledge of the multiple conditions that emulate it, and treatment requires addressing factors that modify the disease. This comprehensive, single reference will help practitioners identify and care for co-morbid conditions and improve asthma treatment. |
| soap note asthma: Natural Ventilation for Infection Control in Health-care Settings Y. Chartier, C. L Pessoa-Silva, 2009 This guideline defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, describing the basic principles of design, construction, operation and maintenance for an effective natural ventilation system to control infection in health-care settings. |
| soap note asthma: Documentation Basics Mia L. Erickson, Becky McKnight, 2005 Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. Necessary for both students and clinicians, Documentation Basics: A Guide for the Physical Therapist Assistant will teach and explain physical therapy documentation from A to Z. Documentation Basics: A Guide for the Physical Therapist Assistant covers all of the fundamentals for prospective physical therapist assistants preparing to work in the clinic or clinicians looking to refine and update their skills. Mia Erickson and Becky McKnight have also integrated throughout the text the APTA's Guide to PT Practice to provide up-to-date information on the topics integral for proper documentation. What's Inside: Overview of documentation Types of documentation Guidelines for documenting Overview of the PTA's role in patient/client management, from the patient's point of entry to discharge How to write progress notes How to use the PT's initial examinations, evaluations, and plan of care when writing progress notes Legal matters related to documentation Reimbursement basics and documentation requirements The text also contains a section titled SOAP Notes Across the Curriculum, or SNAC. This section provides sample scenarios and practice opportunities for PTA students that can be used in a variety of courses throughout a PTA program. These include: Goniometry Range of motion exercises Wound care Stroke Spinal cord injury Amputation Enter the physical therapy profession confidently with Documentation Basics: A Guide for the Physical Therapist Assistant by your side. |
| soap note asthma: Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners Thanavaro, Karen S. Moore, 2016-03-15 « Clinical Decision Making for Adult-Gerontology Primary Care Nurse Practitioners provides a systematic approach to clinical decision making for a wide variety of commonly encountered primary care issues in adult and geriatric practice. Unlike other textbooks, it details a progressive approach to handling such issues by focusing on the complete visit from history intake through management and follow-up care. The goal of this text is to enable students to learn a systematic approach to clinical problems and use evidence-based guidelines to direct their management decisions. Designed for both the student and the newly practicing NP, this text serves as a guide to increase the practioner's confidence with the application of assessment skills, diagnostic choices, and management approaches. Throughout the text students will find guidelines for the adult-gerontology nurse practitioner role as well as a real-life case studies that demonstrate what an NP may encounter in the clinical practice environment. The text is written at an application level, employs up-to-date evidence-based literature, and features practice questions-all of which make this a strong resource for certification preparation. »-- |
| soap note asthma: Cytopathology Review Fang Fan, 2022-12 This new edition provides trainees with a comprehensive review of cytopathology, presented as multiple choice questions with answers and detailed explanatory notes. Divided into twelve chapters, the book covers different body systems including the respiratory tract, breast, thyroid, lymph nodes, liver, gastrointestinal tract, and much more. Each topic covers key aspects of modern cytopathology including diagnostic criteria, reporting systems, ancillary testing modalities, molecular mechanisms of diseases, and clinico-pathological correlations. All chapters have been fully updated and questions are in line with those trainees may encounter in American Board of Pathology examinations. Key learning points are summarised at the end of each topic. Authored by renowned pathologist Fang Fan from City of Hope Medical Centre, California, the third edition of this book is highly illustrated with clinical images and figures. The previous edition (9789352700462) published in 2017. |
| soap note asthma: CRC Desk Reference for Nutrition Carolyn D. Berdanier, 2016-04-19 Following in the tradition of its popular predecessors, the CRC Desk Reference for Nutrition, Third Edition explains hundreds of terms commonly used in medicine, food science, metabolism, physiology, and nutrition. Thoroughly updated and expanded to reflect major advances over the past decade, this reference lists entries alphabetically and cross-r |
| soap note asthma: Mosby's Fundamentals of Therapeutic Massage - E-Book Sandy Fritz, 2016-01-28 Success in massage therapy begins with a solid foundation in the fundamentals! Mosby’s Fundamentals of Therapeutic Massage, 6th Edition helps you build the skills you need, from assessing problems and planning treatment to mastering massage techniques and complementary bodywork. Case studies bring concepts to life, and guidelines to professionalism include topics such as ethics, legal issues, and best business practices. ‘How-to’ videos on an Evolve companion website demonstrate manipulation techniques, body mechanics, positioning and draping, and more. If you want to prepare for certification exams and succeed in practice, this resource from massage therapy expert Sandy Fritz is your text of choice. Research Literacy and Evidence-Based Practice chapter includes new research findings and explains how research is done, and how to read and understand it. Comprehensive coverage includes all of the fundamentals of therapeutic massage, including massage techniques, equipment and supplies, hygiene, working with special populations, and business considerations; it also prepares you for success on the National Certification Exam (NCE), the National Certification Exam for Therapeutic Massage and Bodywork (NCETMB), and the Massage and Bodywork Licensing Examination (MBLEx). Over four hours of video on Evolve demonstrate techniques and body mechanics — each clip is narrated and performed by author Sandy Fritz — and include a demo of practice management software. An entire chapter is dedicated to case studies which offer practice with clinical reasoning and prepare you to address common conditions encountered in professional practice. Step-by-step, full-color photographs demonstrate massage techniques and protocols by body area. A workbook/textbook format facilitates study and review with matching exercises, fill-in-the-blank questions, drawing exercises, and critical thinking questions. Coverage of body mechanics helps you to create an ergonomically effective massage environment and to determine appropriate pressure, drag, and duration application while applying massage methods. A spa chapter describes the massage therapy services offered at spas and looks at the spa as a possible career track in massage. Adaptive Massage chapter explains how to address the needs of specific populations, from pregnant women and infants to hospice patients and people with physical impairments. Example boxes reinforce specific concepts by showing real-life situations. Coverage of multiple charting methods helps you develop record-keeping and documentation skills, including SOAP and computer charting with simulation on Evolve. Foot in the Door boxes outline the professional skills expected by prospective employers. Learning features include chapter outlines, objectives, summaries, key terms, practical applications, and workbook sections. In-depth HIPAA coverage shows how to store records in a HIPAA-compliant manner and describes HIPAA requirements and training. |
| soap note asthma: Respiratory Care , 1997 |
| soap note asthma: Natural Baby and Childcare Lauren Feder, M.D., 2014-02-04 The Essential Parents' Guide to the Best Conventional and Natural Medicines for Your Child From feeding to healing, clothing to washing, raising children naturally can be a daunting task--unless you know how. Natural Baby and Childcare shows you how to complement conventional therapy with natural treatments such as homeopathic and herbal medicine; how to bathe your child without using damaging chemicals; and how to find healthy, organic food for your baby. As a physician and a mom, Dr. Lauren Feder skillfully bridges the divide between medicine and motherhood, empowering parents to personalize traditional child-rearing practices to their own child. Natural Baby and Childcare answers common questions such as: * Do homeopathic medicines have any side effects? * What alternatives are there to wasteful or harmful baby products, such as plastic diapers and chemical-laden diaper creams? * Can vaccines cause autism or Sudden Infant Death Syndrome? In addition to shedding light on controversial topics such as antibiotic overuse and vaccination, Dr. Feder offers a complete A to Z guide to treating common childhood conditions naturally and a handy directory of easy-to-use natural medicines and home remedies. With information for children from birth to adolescence, Natural Baby and Childcare is a comprehensive, intelligent, practical, and reassuring guide to raising healthy and happy children. |
| soap note asthma: Respiratory Care: Patient Assessment and Care Plan Development David C. Shelledy, Jay I. Peters, 2021-02-08 Respiratory Care: Patient Assessment and Care Plan Development, Second Edition describes the purpose of patient assessment and then guides the reader through the process of reviewing existing data in the medical record |
| soap note asthma: Acceptance & Mindfulness Treatments for Children & Adolescents Laurie A. Greco, Steven C. Hayes, 2008 The essays in Acceptance and Mindfulness Treatments for Children and Adolescents--which are edited by two luminaries in the field of third-wave behavior therapy--offer a much-needed adaptation of these revolutionary techniques for young people and their families, providing a wealth of new approaches to therapists, counselors, and other helping professionals. |
| soap note asthma: Druggists' Circular and Chemical Gazette , 1869 |
| soap note asthma: Finding a Path to Safety in Food Allergy National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Food and Nutrition Board, Committee on Food Allergies: Global Burden, Causes, Treatment, Prevention, and Public Policy, 2017-05-27 Over the past 20 years, public concerns have grown in response to the apparent rising prevalence of food allergy and related atopic conditions, such as eczema. Although evidence on the true prevalence of food allergy is complicated by insufficient or inconsistent data and studies with variable methodologies, many health care experts who care for patients agree that a real increase in food allergy has occurred and that it is unlikely to be due simply to an increase in awareness and better tools for diagnosis. Many stakeholders are concerned about these increases, including the general public, policy makers, regulatory agencies, the food industry, scientists, clinicians, and especially families of children and young people suffering from food allergy. At the present time, however, despite a mounting body of data on the prevalence, health consequences, and associated costs of food allergy, this chronic disease has not garnered the level of societal attention that it warrants. Moreover, for patients and families at risk, recommendations and guidelines have not been clear about preventing exposure or the onset of reactions or for managing this disease. Finding a Path to Safety in Food Allergy examines critical issues related to food allergy, including the prevalence and severity of food allergy and its impact on affected individuals, families, and communities; and current understanding of food allergy as a disease, and in diagnostics, treatments, prevention, and public policy. This report seeks to: clarify the nature of the disease, its causes, and its current management; highlight gaps in knowledge; encourage the implementation of management tools at many levels and among many stakeholders; and delineate a roadmap to safety for those who have, or are at risk of developing, food allergy, as well as for others in society who are responsible for public health. |
| soap note asthma: Medical Terminology, Documentation, and Coding Anne P. Stich, 2018-01-12 Giving students the strongest possible baseline in medical terminology, along with the how and why it is used in documentation and basic coding, this is a vital text for all students taking courses in the area. It allows readers to use their knowledge immediately in any medical setting (including being a patient), in their workplaces, and in the journey to future careers. Using a body systems approach to medical terminology, this textbook supports students to: Recognize words by constructing medical terms based on root words, prefixes, linking forms, and suffixes. Define, spell, pronounce, and use medical terms, acronyms, and abbreviations in the context of patient care with appropriate documentation and coding examples. Identify anatomical directions, fundamental anatomical terminology, basic physiologic functions, and common pathology of all major organ systems with related medical investigation tools, procedures, and pharmaceuticals. Relate the use of medical language and medical record-keeping to the SOAP format, common medical reports, and coding tools, along with their impact on patient care. Accompanied by plentiful color illustrations and activities, as well as a companion website with resources for both instructors and students, this is a fresh and readable textbook. |
Soap Note Asthma (book) - netsec.csuci.edu
Soap Note Asthma (book) The Ultimate Guide to Writing a SOAP Note for Asthma. Asthma, a chronic respiratory condition affecting millions, demands meticulous documentation for effective management and treatment. For healthcare professionals, accurately capturing patient …
Soap Note Asthma Copy - admissions.piedmont.edu
Accurate and thorough SOAP note documentation is essential for effective asthma management. By adhering to best practices and understanding the legal and ethical considerations, …
Asthma Soap Note [PDF] - netsec.csuci.edu
This comprehensive guide provides healthcare professionals with a structured approach to creating thorough and accurate asthma soap notes, covering key components and best …
Soap Note For Asthma [PDF] - netsec.csuci.edu
comprehensive guide will walk you through creating a perfect SOAP note for asthma, covering all essential components – Subjective, Objective, Assessment, and Plan – with specific examples …
SOAP Notes Format in EMR - Florida State University College …
Standard Elements of SOAPnote. or History of major health or genetic disorders in family, including early death, spontaneous abortions or stillbirths. General: Well appearing, well …
ASTHMA PROGRESS NOTE - CHCS
ASTHMA PROGRESS NOTE Name: DOB: Age: Date: C/C: Medical History (This present illness): Recent Hospitalization/ED Visits: Self-Treatment of Asthma Exacerbation: None One Per …
Example Soap Note For Child With Asthma (book)
Example Soap Note For Child With Asthma (PDF) WEBApr 22, 2024 · A SOAP note records an encounter with a patient. The components are Subjective (what the patient tells the recorder), …
Example Soap Note For Child With Asthma (book)
Identifying allergies and asthma - Preventing attacks - Minimizing triggers and avoiding allergens - Choosing medications wisely - Explaining allergies to young children - Helping children of all …
HSH - Asthma Documentation and Billing Examples - Home …
Asthma. Asthma, sometimes called bronchial asthma or reactive airway disease, is a chronic lung disease that makes it harder to move air in and out of the lungs 1,6. It can be serious, life …
Pharmacy Skills Laboratory Guide to Writing a SOAP Note
Discuss how the patient’s drug therapy conforms to standard, evidence-based drug therapy recommendations. For example, discuss how well a patient’s currently therapy matches JNC7 …
University of Vermont Graduate Writing Center SOAP Notes: …
A SOAP note is a written document that a healthcare professional creates to describe a session with a patient/client. The information included is: Subjective, Objective, Assessment, Plan …
SOAP #1 Episodic SOAP Note
GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND …
Whether the practitioner writes a SOAP note or a History and Physical will depend on the particular setting wherein the problem is being addressed. Usually, an H/P is done for an initial …
College of Pharmacy Standardized SOAP Note, Rubric,
The following document outlines the Oregon State University College of Pharmacy SOAP note framework and outlines the guiding philosophy and principles of a standardized, educationally …
Pediatric SOAP Note - Weebly
Asthma: History and Physical findings - michiganrc.org
Pediatric Pulmonology. Key Symptom Indicators for Considering. Diagnosis of Asthma. Wheezing—high-pitched whistling sounds when breathing out. A lack of wheezing and a …
November 23, 2010 1:30 PM, Internal Medicine Clinic HPI: Mr.
1. Asthma exacerbation: Patient is slightly tachypneic and wheezing, making an asthma exacerbation a very likely occurrence. Wheezing and urge to cough with forced expiration is a …
Example Soap Note For Child With Asthma (PDF)
Example Soap Note For Child With Asthma (Download Only) parents and caregivers trying to cope with the challenges of childhood asthma and allergies. This well-organized guide covers …
Example Soap Note For Child With Asthma - mj.unc.edu
'Soap note asthma example pp nichebooks com April 30th, 2018 - Asthma SOAP Note Example Asthma SOAP Note asthma soap note kyaap org Details File Format PDF Size 48 KB …
Soap Note Asthma (book) - netsec.csuci.edu
Soap Note Asthma (book) The Ultimate Guide to Writing a SOAP Note for Asthma. Asthma, a chronic respiratory condition affecting millions, demands meticulous documentation for …
Soap Note Asthma Copy - admissions.piedmont.edu
Accurate and thorough SOAP note documentation is essential for effective asthma management. By adhering to best practices and understanding the legal and ethical considerations, …
Asthma Soap Note [PDF] - netsec.csuci.edu
This comprehensive guide provides healthcare professionals with a structured approach to creating thorough and accurate asthma soap notes, covering key components and best …
I. Identifying Data: A. Initials: NM Age: 8 YEARS DOB: 03-25 …
Asthma and cough- Provided couseling related to asthma which included teaching correct technique of inhaler and return demonstration by patient. Triggers were also discussed that …
Soap Note For Asthma [PDF] - netsec.csuci.edu
comprehensive guide will walk you through creating a perfect SOAP note for asthma, covering all essential components – Subjective, Objective, Assessment, and Plan – with specific examples …
Example Soap Note For Child With Asthma (book)
Example Soap Note For Child With Asthma (PDF) WEBApr 22, 2024 · A SOAP note records an encounter with a patient. The components are Subjective (what the patient tells the recorder), …
Example Soap Note For Child With Asthma (book)
Identifying allergies and asthma - Preventing attacks - Minimizing triggers and avoiding allergens - Choosing medications wisely - Explaining allergies to young children - Helping children of all …
ASTHMA PROGRESS NOTE - CHCS
ASTHMA PROGRESS NOTE Name: DOB: Age: Date: C/C: Medical History (This present illness): Recent Hospitalization/ED Visits: Self-Treatment of Asthma Exacerbation: None One Per …
HSH - Asthma Documentation and Billing Examples - Home …
Asthma. Asthma, sometimes called bronchial asthma or reactive airway disease, is a chronic lung disease that makes it harder to move air in and out of the lungs 1,6. It can be serious, life …
Pharmacy Skills Laboratory Guide to Writing a SOAP Note
Discuss how the patient’s drug therapy conforms to standard, evidence-based drug therapy recommendations. For example, discuss how well a patient’s currently therapy matches JNC7 …
University of Vermont Graduate Writing Center SOAP …
A SOAP note is a written document that a healthcare professional creates to describe a session with a patient/client. The information included is: Subjective, Objective, Assessment, Plan …
SOAP Notes Format in EMR - Florida State University College …
Standard Elements of SOAPnote. or History of major health or genetic disorders in family, including early death, spontaneous abortions or stillbirths. General: Well appearing, well …
GUIDELINES FOR WRITING SOAP NOTES and HISTORY …
Whether the practitioner writes a SOAP note or a History and Physical will depend on the particular setting wherein the problem is being addressed. Usually, an H/P is done for an initial …
College of Pharmacy Standardized SOAP Note, Rubric,
The following document outlines the Oregon State University College of Pharmacy SOAP note framework and outlines the guiding philosophy and principles of a standardized, educationally …
Pediatric SOAP Note - Weebly
1. Asthma exacerbation: a. chronic b. inadequately controlled Possible etiology: When irritants enter into the airway of a person with asthma, the airway constricts which make the area prone …
SOAP #1 Episodic SOAP Note
Chest/lungs: Denies cough, wheezing, history of asthma or COPD. Positive for dyspnea exertion. GI: Denies dysphagia, heartburn, nausea, vomiting, constipation, diarrhea, blood in stool, or …
November 23, 2010 1:30 PM, Internal Medicine Clinic HPI: Mr.
1. Asthma exacerbation: Patient is slightly tachypneic and wheezing, making an asthma exacerbation a very likely occurrence. Wheezing and urge to cough with forced expiration is a …
Asthma: History and Physical findings - michiganrc.org
Pediatric Pulmonology. Key Symptom Indicators for Considering. Diagnosis of Asthma. Wheezing—high-pitched whistling sounds when breathing out. A lack of wheezing and a …
Example Soap Note For Child With Asthma (PDF)
Example Soap Note For Child With Asthma (Download Only) parents and caregivers trying to cope with the challenges of childhood asthma and allergies. This well-organized guide covers …
Example Soap Note For Child With Asthma - mj.unc.edu
'Soap note asthma example pp nichebooks com April 30th, 2018 - Asthma SOAP Note Example Asthma SOAP Note asthma soap note kyaap org Details File Format PDF Size 48 KB …
