Graphical patient timeline in Soap format



Usually we use to write fever chart in *SOAP* format- top to bottom.

 S- subjectivecomplaints- 
Next day , mention the same, whether it was subsided or not .

 O- In objective, I used to include those parameters only, which I want to monitor daily... ( because I don't want to make it clumpsy).

Like - abdominal girth in Ascites .
Daily weight measurement in Heart failure.

 A- in Assement, I used to mention the investigations,which I used to monitor daily.

Like - TLC in Sepsis .

But my friends and other interns used to mention every investigation though it was normal, which I was not interested.

 P- plan . .. please mention the drugs along with interventions that you are giving to patient...
On next day , mention if any new drugs were added ..
Or mention if any drug was stopped.

Comments

Post a Comment

Popular posts from this blog

60 /Female with slowness of movement/ Long case

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." Chief compliants :  1) Slowness of movements since 1 year . 2) Involuntary movements of the Left upper limb. 3) Slowness in speech since 1 year. History of present illness :  60 year old female,who is a mother of 3 children (  1 son and 2 daughters ), labour by occupation ( goes to agriculture field ) was apparently asymptomatic 1 year back, then developed Slowness of movements which was insidious onset, gradually progressive not associated with any wea
Read more

DURGAKRISHNA DISSERTATION REVIEW

THESIS :  TITLE : Predictors of outcomes  in patients of Chronic kidney disease.  PROBLEM STATEMENT : INTRODUCTION :  AIM:   To identify the outcomes  in patients admitted to rural hospital with Chronic kidney disease . OBJECTIVES:  1)  To analyze the etilogy and comorbidities.. 2)  To look into the presence of Smoking and alcohol consumption.  3)  Nutritional assessment of the patients. 4)  To analyze the presence of various acute and Chronic complications. 5)  To analyze the abnormalities in Urinalysis and presence of Viral markers and special investigation ( if done)  6)  To Observe and follow up if these patients admitted to the rural hospital.  PATIENTS AND METHODS: PLACE OF STUDY: Department of General medicine , Kamineni Institute of Medical Sciences, Narketpally. STUDY PERIOD: October 2020-September2022 STUDY DESIGN : Observational Study  SAMPLING: Convenient Sampling(30 patients)  INCLUSION CRITERIA: 1. Patients of any gender above or equal to 18yrs of age at the time of prese
Read more