SOAP note：医学文件的书写和汇报（格式）

SOAP note:

 什么是SOAP Note？

SOAP Note我个人理解是国外医疗卫生体系中的一种病例或者文件的记录方法，全称为：Subjective, Objective, Assessment and Plan。不管是国外的医疗机构还是保险公司都认可和接受及普遍使用这种格式。

 

记得已开始学的时候还是很好理解的，但是具体到运用的时候，我那时候并不是很好。考试考SOAP Note，试卷上出现的是一段病人的介绍，然后让你选出什么是SUBJECTIVE, 什么是Objective，什么是Assessment和Plan。虽然说那时候理解了字面意思，但是考试的时候那些是客观的，哪些是主观的，有时候还是会搞混。那时候，还有一个困难是SOAP Note里面会出现许多的缩写，这些缩写是欧美医疗相关人员必须掌握的缩写，而我花了很久，才背会了一些，现在还在背着。

 

一晃眨眼间，一年过去了，我来到了病房里，这时候我才真正感觉到为什么老外会想出这种肥皂笔记，很是适用，让你知道临床的入院记录里该写些什么，哪些是可靠的，哪些是主观的。而那些缩写，也变得十分的有用，如来了个病人说头痛2天，SOAP Note可以写成：p.t. c/o. headache for 2 days，诊断为感冒，SOAP Note可写成¯c Dx of cold。一年后，重翻那本曾经陪伴我的Writing SOAP Notes这本书，不能不感慨：things change, people change.

废话了。

请看下面的例子：

Sample SOAP note

 

Subjective:

 

Chief Complaint: A brief statement of why the patient is here, E.R., Office, Hospital? Should be in patients own words and in quotation.

 

History of the Present Illness/Chief Complaint (HPI): A summary of the events and symptoms over the course of the developing illness. If pain is the symptom you can include mnemonics NLDOCAT or OPQRST. Also if not pain can include elements of the mnemonics i.e. Onset, Duration Aggravating/Alleviating factors. Should also include selective system reviews extracted from the comprehensive Review Of Systems(ROS) pertinent to the presenting complaint. That is, if the chief complaint were abdominal pain than either of the mnemonics above would apply and the GI systems review should be incorporated in the HPI. The HPI gives many physicians in training difficulty. It will develop and improve over the course of your career as you better understand the various symptom manifestations of disease which can draw symptoms from many of the various systems within the comprehensive ROS. For example abdominal pain may manifest with joint pain and a skin rash which might prompt the knowledgeable physician to include the symptoms from the Skin and Rheumatologic systems reviews routinely.

Can include an update on past medical history, past surgical history, allergies, medications, social history, and family history especially if it has been some time since the last visit.

 

Objective:

 

Perform either a focused or more extensive physical examination based on the your clinical judgement and the presenting complaint. See H&P for details of Physical examination.

 

Assessment/Plan:

 

Labs (can use accepted shorthand notational schematic representation)

Special studies: EKG, PFT, XRAY, CT, MRI, Ultrasound, Stress Test results.

Generate a problem and/or diagnosis list.

Numbered problems listed with differential diagnosis, or rule outs followed by planned tests and treatment strategies to determine etiology.

Numbered diagnosis listed followed by planned testing and treatment strategies.

 

come from: http://web.etiandi.com/?uid-5773-action-viewspace-itemid-3050

转载于:https://www.cnblogs.com/pentiunz/archive/2010/06/24/1764428.html