HOW TO WRITE A SOAP NOTE

What is a SOAP NOTE?

SOAP是一個幫助醫療人員快速了解病人病人病情的病例記錄方式，雖然我們在學校常常說要附上佐證，來證明你的評估和治療計畫是有所根據的，例如：參考Micromedex、PubMed、UpToDate或者是其他資料庫收錄的實證文獻。

但是如果附上太多文獻會使得病例報告變得非常冗長，所以適時的縮減也是很重要的，我們需要刪減掉大部分醫療人員都知道的知識，補充可能會忽略的注意事項。

由於專業的不同，不同專業的醫療人員所寫的SOAP NOTE會有些許的不同，例如：醫師會著重筆墨在治療計畫上，而藥師則會在用藥提出建議。

臨床藥師通常會根據自己的專業提出用藥的建議，例如：
  1. 根據最新的guideline提出用藥建議
  2. 找出可能藥物和藥物間的交互作用，避免造成病人傷害，或無效的治療
  3. 藥物根據病人的情況做出劑量和頻次調整的建議
  4. 註明用藥的注意事項，以及潛在的副作用；如果產生副作用可以選擇的治療方式及調整

SOAP NOTE和CASE REPORT的不同

SOAP NOTE相較於CASE REPORT會比較針對單一症狀，且觀察的時間比較短，可能會是1天而已，但CASE REPORT會紀錄整個病人從入院到離院所有重要事件。換句話說，CASE REPORT通常篇幅會比SOAP NOTE還要來的長很多。

以下影片只是簡單介紹SOAP NOTE和CASE REPORT的不同


Comments

Post a Comment

Popular posts from this blog

Plug-ins vs Extensions: Understanding the Difference

In the world of web browsers, terms like "plug-ins" and "extensions" are often used interchangeably, but they refer to different types of software add-ons that enhance browser functionality. Both serve to expand the capabilities of browsers, but they do so in distinct ways and have different implications for users and developers. This essay clarifies the differences between plug-ins and extensions, their respective roles, and their current relevance in modern web browsing. 1. Definitions Plug-ins Plug-ins are software components that add specific capabilities to larger software applications. In the context of web browsers, plug-ins are used to handle content that the browser itself cannot process natively. Historically, plug-ins were essential for enabling functionalities such as viewing PDF files, playing Flash animations, or streaming certain video formats. Examples of popular plug-ins include: Adobe Flash Player : Enabled ...
Read more

Neat-Flappy Bird (First Model)

NEAT (NeuroEvolution of Augmenting Topologies) was introduced in the field of artificial intelligence in 2002 by Kenneth O. Stanley and Risto Miikkulainen. NEAT is an evolutionary algorithm designed to evolve artificial neural networks with complex structures and behaviors. Unlike traditional neural network training methods, NEAT evolves both the weights of connections and the structure of the network itself, allowing for the emergence of increasingly sophisticated solutions to complex problems. It starts with a population of simple networks and gradually evolves them over generations, favoring networks that perform better at the task at hand. NEAT's ability to dynamically adjust neural network architectures, allowing for the addition and removal of nodes and connections, makes it particularly effective in solving problems where the optimal network structure is not known in advance. The technology has found applications in various fields, including gaming, robotics, and opt...
Read more

An Overview of Modern Authentication Technologies

In the realm of software development and network security, robust and versatile authentication mechanisms are paramount to ensure secure access to services, APIs, and remote systems. Among the most widely utilized technologies are Personal Access Tokens (PATs), SSH keys, OAuth 2.0, API keys, and Kerberos. Each of these methods offers unique features and advantages, catering to different security needs and use cases. Personal Access Tokens (PATs) Personal Access Tokens (PATs) are a modern solution for accessing services and APIs over HTTPS. They function as secure, scoped tokens that are generated by the service provider. One of the most significant advantages of PATs is their ability to be restricted to specific actions or scopes, thereby minimizing the potential damage if a token is compromised. Additionally, PATs can be set to expire after a certain period, enhancing security by limiting the window of vulnerability. The ability to revoke tokens at any time furthe...
Read more