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Understanding SOAP Formats for Clinical Rounds

Many hospitals that are conducting clinical rounds in hospitals at some point have the students present a case to which they must discuss at rounds. The above step includes nurses, attending physicians and residents who will listen to your presentation and try to have an idea of what is going on with the patient being discussed. So, what is a SOAP format?

It needs to be noted that there includes a standard format for providing information about a patient’s background which most clinicians use to both present and write some of the notes seen. A SOAP note which is an acronym that stands for Subjective, Objective, Assessment, and Plan is a method often employed in the healthcare industry and by the providers in ensuring that they have noted in a patient’s chart along with other common formats.

Most of the documentation is seen as an integral part practice workflow that begins from the appointment scheduling of the patient to write out notes to medical billing. SOAP note originated from the then Problem Oriented Medical Record (POMR) that was developed by Lawrence Weed. The above method was initially developed for physicians since they were the only health care providers allowed to write in a medical record. Today, the medical and health industry has evolved as it is widely adopted as a way of communication among health workers.

A soap note contains information about the patient that is written and presented in a specific order including critical components. Many of the notes are used in hospitals for detailing some of the medical histories, admission notes and other documents that are in the chart of a patient. It is evident that with the sudden rise in technology, many hospitals are now using electronic medical records that have templates making it easier for one to enter information into a SOAP note format. It has become a necessary requirement for many healthcare clinics to use SOAP notes as it is the most effective way of communicating among nurses, physical and occupational therapists, and doctors. Medical schools these days must involve the use of SOAP notes putting more emphasis on the format that is required by them when they join the professional industry.

The main reason for most of these hospitals having SOAP notes is to have a standard format that is necessary for organizing outpatient information which is key to ensuring the success of a patient’s life. For one to understand the SOAP format, it is vital for them to understand what each section entails and what it talks about.

Subjective: It is the first letter of the acronym which refers to the subjective observations that are usually expressed in a verbal manner by the patient. Most of the information shared is usually about how they feel, basically symptoms. The main reason why it is considered subjective is that there is no way of measuring information relayed by two patients. The subjective section of your SOAP notes should include a mnemonic known as OLD CHARTS.

Onset: That is used in determining from the patient information to how the symptoms started

Location: refers to a part in the body where the pain is present.

Character: it refers to the type of pain that the patient is enduring which can either be dull, aching etc.

Alleviating factors: Used in determining some of the conditions that reduce or eliminate the symptoms and whether anything makes them worse.

Since medical practitioners have already established where the source of pain, does it radiate anywhere else in the body?

Temporal patterns: Shows whether symptoms have a set pattern which keeps on occurring.

determining whether there are other symptoms related to the condition.

Objective: It is the second section of the SOAP note which involves objective observations. It relates to factors one can see, hear, feel and even smell. In these sections, one includes the vital signs that are seen from the patient such as their pulse, temperature, and even respiration.

Assessment: That refers to how one is going to assess some of the issues the patient is currently undergoing. One assesses the condition or diagnosis a patient has.

Plan: it is the last section of the acronym SOAP that shows how one is going to deal with the patient’s problem. It can include ordering additional tests that rule out or show a certain diagnosis. Here, the patient can be subscribed to more treatment or even slotted for surgery.

How to Write Nursing Powerpoint Papers

Writing a nursing paper either in word or PowerPoint needs to be done appropriately to ensure that the message given is clear and conveyed in a great manner. Writing PowerPoint papers needs to be short and concise. So, what are some of the ways to writing Nursing PowerPoint Papers?

Before embarking on your paper, it is vital for the student to first Pre-write a snippet to what they are going to talk about in the whole presentation. In this part, it is vital for the student to brainstorm, come up with a thesis purpose, and to know the kind of people that are going to benefit from the information being written.

The next step will be to write multiple drafts that will help in conveying the message that you are putting across to the readers. It is imperative for one to do this since it helps ensure that the message put across gels between each paragraph.

Revising one’s work after writing your draft is critical as it helps the student review the whole presentation, altering and improving some of the texts or sections that need revision. It is also a wise thing to so since most of the people require work written in professional writing. Having the help of a friend or a member of the same faculty helps you in the identification to some of the areas that you might have missed whenever you were proofreading your work. The reason for doing the above helps the student identify some of the terminologies that are not easy to spot with the naked eye.

It is imperative for one to edit their work and to constantly review that style of presentation to make sure that it matches with their audience. The nursing PowerPoint paper needs to contain the main title, ensure that the format is alright, headings or subheadings, and grammar that is correctly written and flows from the top to the last paragraph. One can then proofread their work after examining the final draft ensuring that there are no grammatical errors in your presentation and if necessary use a grammar checker that helps iron out some of the issues which some of your colleagues might have missed.

Whenever one is writing a prewriting a Nursing PowerPoint paper, it is imperative that they start earlier which will help in their imaginative process. They should take breaks on their work which helps the student come up with fresh ideas that are required in their PowerPoint paper. Commitment is another key condition that most of these students should have as it helps them finish their coursework at a faster time.

Always ensure that the environment you are working in is quiet and is a private area that you are comfortable with. It is always great to share your main idea with a close colleague or a friend who can help start up the rough idea plus constantly reminding you of what to do or where needs to be corrected.

Ensure that your Nursing PowerPoint presentation has an introduction where it explains the problem statement clearly highlighting a brief background to the problem.it should also explain the purpose of your research to the readers and viewers and how it seeks to solve a problem or contribute further in the ever-growing knowledge base. One should also to explain the significance of the research asking yourself questions to whether they fill a needed gap in the knowledge base.

Your second chapter should be the Literature review which is a brief paragraph that has two sections where the first section talks about a brief history to the problem while the second section explains what has been done to date about the said problem.

Students writing Nursing PowerPoint papers need to ensure that their presentations have a neat organization with lots of Clip Arts and diagrams that will help keep the audience interested in the content. The content should also have flow detailing a step by step slide information on how information is channeled from one slide to the other.

What  is  the  importance  of  the  microorganisms  which  live  inside  and  on  humans?

Importance of microorganisms in human life

Microorganisms are microscopic organisms that describe a bacterium, fungus or a virus in the body. These microorganisms play a vital role in maintaining strong immunity and good health in general. Microorganisms inhabit different areas of the body, including the skin, nose and the digestive system. The number of microbes in the human body outnumbers the number of human cells in the body ten times.

This was reported in 2014 and it is supported by scientific literature. There are both positive and negative effects of microorganisms. There are an estimated 30pc of bacteria that are disease-causing pathogens which can have negative effects. For example, mold can trigger bad respiratory problems, and allergies if they grow either in the workplace or the home. The tiny organisms in our bodies can be referred to as microbes, or microbiome collectively.

What they do

The human microbiome is very unique and diverse, in that no two microbiomes are the same. These microorganisms form an essential part of the human immune the system and they influence the metabolism and modulates drug interactions. Microbes are also beneficial. For example, the bacteria from lactic acid is used to make yogurt, cheese sour cream, and other fermented products.

Effects

The microbes that live in association with humans on the surface of the body are called the normal flora. For example, the Lactobacillus and Bifidobacterium protect their hosts from infections and promote better nutrition and health. They also assist in purifying wastewater in water treatment centers and facilities. The atmospheric nitrogen is also transformed to ammonia an important component for enhanced agriculture.

The Negatives

In our homes, microscopic fungi can stain carpets and algae on the walls can grow on the paint making it difficult and costly to remove. Due to their microscopic size, it is impossible to see them growing until they are large enough for the naked eye. Often having already made a regrettable mess. It is also common to find mold on clothing and footwear that has not been worn in a long time. This happens especially in moist areas.

Microbes are agents for food spoilage. Causing food to go bad when exposed or not kept in proper storage. As a result, they may cause food poisoning for people who consume this food unknowingly. To get rid of microbes, high temperatures may be required or very low temperatures that will kill them off slowly.

Should  home  nursing  be  required  to  have  more  oversight?

Should home nursing be required to have more oversight?

Home nursing can become a requirement especially if the patient receiving care has a terminal or chronic illness. This will apply to patients who may be suffering from diseases like cancer at an advanced stage or even dementia at an advanced stage. It could simply be someone who needs assistance at home after breaking a leg or after having been in an accident. Home nursing is required for a number of reasons, and those with the means to pay for their services, do engage them from time to time.

Nurses are chosen to care for a patient based on their experience in treatment. If the patient requires physical therapy, a nurse who has experience in this field is likely to be recommended for the job. Similarly, those who care for the elderly, or senile, terminal patients or even recovering from an accident are all chosen based on their skills and experience.

For nurses who have no experience, there are entry-level jobs, and home nursing positions they can take. However, they do not involve a lot of responsibility. Most nurses gain experience while they are still in school because most training programs include clinical training. This gives inexperienced nurses a chance to get practical experienced before finishing their studies to gain experience outside the school.

There could be concerns where home nursing occurs because unfortunately, a nurse may want to take advantage of an ill patient. It could be through accessing personal financial information, misuse of the resources provided by the family. To prevent any misbehavior on the part of the nurse, or misconduct a nurse of higher ranking can supervise the home nursing by checking in periodically. This will give the other nurse a chance to observe the home treatment, and ask the patient about the care they have been receiving.

They will also be able to assess whether the nurse appointed is doing a job as recommended and to the expected standards. Moreover, they will have the chance to assess the environment and prove that it is conducive and comfortable for both the nurse and the patient. This will avoid any malpractice or harassment of any kind towards either party.

Every arrangement should be made to suit the parties involved. It can be customized so that if a patient prefers to see the supervisor more often, it can be arranged. This may also be dependent on the kind of illness of the patient.

Do  nurses  receive  enough  “On  the  job”  training?

Do nurses receive enough “On the job” training?

Every career needs constant and consistent learning. To get better at anything, we need to keep practicing and take time to learn new things. This means having a better technique, and new knowledge that improves your work and the people who receive your services. This applies everywhere, and nursing is not an exception. In fact, for work as delicate as nursing, or the medical practice in general then it is even more important to be skilled at what you are doing. This is because the services carried out by people in the medical profession are to assist in saving lives.

Nurses can join a medical facility or home with an associate’s degree and begin practice. They can also do the same with a bachelor’s degree but at a higher level and with higher pay. Like any other job, to get a promotion and better benefits you need to work for them. Get better qualifications through education and become more skilled through experience and practice. Working is a shift will allow for some down time to catch up on some reading, pursue and degree.

Alternatively, one may choose to work a little bit longer, not just to make more money through overtime but also to gain more skills. Being on a particular doctor’s service whom you admire can teach you a lot.

Depending on their practice, or even how they treat their patients’ nurses can learn a lot when they choose to learn and work with doctors productively.

Having an experienced nurse as a mentor can also contribute greatly to one’s success. They impart knowledge on best treatments and how to manage shifts and your time to be productive. It is understandable that some health facilities may be understaffed and hence nurses are very tired. Some receive too many patients, that their facilities and staff are working more than their capacity. Asking for better work conditions can make a difference in your immediate working environment to help you receive the kind of training you need.

Additionally, the benefits of working to capacity at a health facility are that nurses are forced to take on more challenging tasks that enable them to learn. The research, ask questions and do more to be able to treat their patients with competence and efficiency. Nurse training programs typically last for a year for certificate level and longer the higher your qualifications.

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