3 ms·
The SOAP note (an acronym for subjective, objective, assessment, and plan)is a methodology for documenting a patient's condition on first examination by a medic
by ckk175 4y ago
The SOAP note (an acronym for subjective, objective, assessment, and plan)is a methodology for documenting a patient's condition on first examination by a medical professional. It serves as an excellent cognitive framework for medical professional to assess their patients.
The SOAP Note originated from the early work done by Dr. Lawrence Weed (an American physician, researcher, educator, entrepreneur and author, who is best known for creating the problem-oriented medical record as well as one of the first electronic health records).
SOAP notes are commonly found in Electronic Medical Records as a means to succinctly communicate patient information in a standard format and are particularly useful between hand-offs between medical professionals.
Modern Electronic Health Record (EHR) Systems offer a great deal more in terms of adding additional diagnostic information as well as a longitudinal patient record but the basics SOAP note could prove immensely valuable as we think about how to design a system that can empower Community Health Workers (CHWs).
SOAP Note in Practice (highly simplified for an illustrative example)
Situation: A medical professional encounters an individual who seeks or is identified for medical care
Subjective data collection
Shaking chills
Muscle ache
Fatigue
Objective data collection
Fever of 102 F (suing a Bluetooth connected thermometer or a cell phone camera based temperature detector)
Malaria Rapid Diagnostic Test (RDT) administered - shows positive
Assessment
The Subjective and Objective information is collated in the medical professionals mind and and she assesses that the patient shows indications of Malaria
Plan
Based on the Subjective and Objective and informed by the Assessment, the medical professional develops a Plan that is specific to the situational context - in this case it may involve sending the patient for a confirmatory Malaria confirmatory test or in some cases starting them directly on anti-malarial treatment.
The SOAP note allows a complicated problem to be broken down into components to then become a simple problem. However, in Global Health today, this complicated problem is treated as a complex problem because it is felt that only a doctor with decades of experience and a medical degree would be able to accurately diagnose and treat Malaria.
- ghufran_syed 4y agoI have a few questions for you / your AI? 1) what if the malaria test costs a lot - should i do it on this patient? Or save those resources for a different patient? before this patient ever arrived, we need to decide if should we spend $20 on the malaria test kit…or treat 20 kids with the mumps,measles,rubella vaccine for $1 each? 2) what if the test is negative? now what do i do? could it be a false negative? how do I decide? 3) what if the patient has a headache as well? could this be bacterial meningitis? 3a) if so, should I give them antibiotics now or after a lumbar puncture? 3b) could they have both malaria and bacterial meningitis? should i do a lumbar puncture to confirm or rule out bacterial meningitis? but doing an LP in the presence of cerebral edema / raised intracranial pressure can cause severe brain damage and death - should I do a CT scan of the brain to rule out raised intracranial pressure first? and so on. There are some conditions that are so clearcut and some tests that are so effective, that you could safely diagnose it algorithmically…and a whole bunch that you can’t
- ckk175 4y agoThe malaria RDT costs about $0.25. To be clear this is a screening test - not a diagnostic test. An actual diagnostic would involve taking a small blood sample, smearing on a slide and looking for malaria plasmodium under a microscope. Not expensive but time consuming and requires a microscope and a trained technician.