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SOAP notes
Today is our 15 months anniversary since I started dating with Michi. Thank you for everthing. I must appreciate her consideration for everything. She even sent me some presents for me sometimes and these stuff have really helped me. So does this time.(OK?) Again, thank Michi.


By the way, Have you guys ever heard the term, SOAP? This term doesn't seem to be familiar to most people. In SOAP notes, each letter represents Subjective, Objective, Assessment, and Plan, respectively, and making SOAP notes is the most basic stuff for clinicians when patients are coming in. It's like a medical record.


When making these notes, we talk with patients to gather a lot of information from them because each patient is the only person who knows his/her actual symptoms. We should diagnosis based on his/her compliment. However it often occurs that even patients don't notice the change in their shapes. In these cases, Subjective assessment does't work out any more and other assessments are gonna be needed.


In subjective area, we are gonna ask patients how they actually feel. For instance, I can ask them

How do they feel since last visits?
How is their symptom today? How are you today?
Do you have any tender or sore? Did you do something special?
Do they have any difficulty in their daily living such as bed mobility, chair transfer, or up or down stairs? Is getting better or getting worse since last time or yesterday?
When do they feel pain? Specific motion? Specific posture? Specific time? Specific whether?
Is there anyway they can decrease pain or uncomfortable.

And we are gonna write their complients or their notices briefly. Since we have to take care of many patients at the same time and can't use much time for just one patient, we have to listen their stories carefully and take notes in a short time.
I guess this is one of the important skill which we shold have when working at a clinic.



In objective, we are gonna evaluate their conditions through the objective perspective and put on SOAP notes what we actually saw or measured objectively.
For example, when the patient improves his ROM (range of motion) or time how long he can maintain his balance on one leg, we are gonna write down about them.
Or we can also put if patients have any problems during doing certain exercises. Like if he tends to shift his weight to right leg, we can write down about that. We shouldn't just guess their conditions or shouldn't put patient's subjective compliments.



In assessment, we are gonna put the reason why they'd changed their conditions or what their actual problems are. If they are doing a certain exercise with problems, we should put in this part we should write down what cause prevent them from doing right exercise. Specifically like objective part, when person tends to shift his weight toward right side, we consider that because his left leg might have weakness comparing the other leg. So in this blank, we are gonna write "his left leg might have weakness"


In the last part, plan part, we are gonna put what kind of treatments or which exercises we are gonna provide to the patients. Like the last example, if person has weakness in his left leg, we are gonna focus on to improve his left leg strength or try to make balance of both leg.
And we are gonna put actual the name and way of exercises in this part.


I tried making this process by myself today. This was my first time actually talking with patient and get information from them.
I got nervous, but thanks to her kind personality, I managed to make them and Mike gave me OK sign from long distance.

I felt good, but at the same time, I also felt helpless in my conversation skill. But I will prepare more for making SOAP notes next time.


I am gonna get right down to this challenge!(Is natural?)


Japanese
洗う(ARAU) to wash something.
I am gonna wash my hands.
(watashi wa te(hands) wo arau). more proper to say ARAIMASU.
try this!!


※please correct the my wrong. I guess there are many weired expression in this blog. I got confused actually. I would really appreciate it if you can check this blog. thanks. and if you have any japanese question, please feel free to ask me.
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