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Health Science Core Chapter 12 and SOAP Writing

McFatter Technical Center Emergency Medical Technician - Basic. Health Science Core Chapter 12 and SOAP Writing. Chapter 12. Determining Meaning. Prefix – word element placed in front of a root to modify its meaning Suffix – word element placed at the end of the root to modify its meaning

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Health Science Core Chapter 12 and SOAP Writing

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  1. McFatter Technical Center Emergency Medical Technician - Basic Health Science CoreChapter 12 and SOAP Writing Revised: August 2007

  2. Chapter 12 Revised: August 2007

  3. Determining Meaning • Prefix – word element placed in front of a root to modify its meaning • Suffix – word element placed at the end of the root to modify its meaning • Root word – main part of a word Revised: August 2007

  4. Common Prefixes • A-, an- : absent, deficient, without • Bi- : two • Brady- : slow • Contra- : opposite, opposed, against • Di- : two • Fore- : in front • Hemi : half • Hyper- : excessive, above, increase • Hypo- : below, deficient, under Revised: August 2007

  5. Common Prefixes • Mal- : abnormal, bad • Micro- : small • Mono- : one • Multi- : many • Para- : beside, beyond, apart from • Peri- : surrounding • Post- : following after • Pre- : in front of, before Revised: August 2007

  6. Common Prefixes • Semi- : half • Sub- : under, below • Super- or Supra- : over, above • Sym- : with, together • Tachy- : fast, rapid • Trans- : across • Tri- : three • Ultra- : excess, beyond Revised: August 2007

  7. Common Suffixes • -algia : painful • -dynia : painful, difficult, bad • -ectomy : surgical removal, excision • -emia : blood • -graph : instrument for recording • -graphy : process of recording • -itis : inflammation • -logy : science of, study of Revised: August 2007

  8. Common Suffixes • -osis : abnormal condition • -pathy : disease • -pnea : breathing • -rhea : flow or discharge • -scope : instrument used to examine or look into a part • -sis : condition or process • -tomy : cutting into, incision Revised: August 2007

  9. Abbreviations • AAOx3 – Alert and orientated times person, place, and time/date • abd – abdomen • ac – before meals • AMI – acute myocardial infraction • amt – amount • ant – anterior • ASA – Aspirin • BM – bowel movement • BP – blood pressure • BS – blood sugar Revised: August 2007

  10. Abbreviations • BVM – Bag valve mask • CA – cancer • CC – chief complaint • CHF – congestive heart failure • CNS – central nervous system • c/o – complaining of • COPD – chronic obstructive pulmonary disease • DNR – do not resuscitate • DOA – dead on arrival Revised: August 2007

  11. Abbreviations • ECG – electrocardiogram • EENT – eye, ear, nose, and throat • EKG – electrocardiogram • ETA – estimated time of arrival • Fx – fracture • H/A - headache • HEENT – head, eyes, ears, nose, and throat • HTN – hypertension • HX – history • IM – intramuscular • IV – intravenous • IVP – intravenous push Revised: August 2007

  12. Abbreviations • kg – kilogram • LLQ – left lower quadrant • LOC – level of consciousness • LR – lactated ringers • Lt – left • LUQ – left upper quadrant • mg – miligram • MI – myocardial infarction • ml – milliliter Revised: August 2007

  13. Abbreviations • NC – nasal cannula • NPO – nothing by mouth • NRB – non-rebreather mask • NS – normal saline • NTG - nitroglycerin • OD – overdose • pc – after meals • PERL – pupils equal and reactive to light • po – by mouth • PRN – whenever necessary or as needed • PTA – prior to arrival Revised: August 2007

  14. Abbreviations • RLQ – right lower quadrant • RUQ – right upper quadrant • SOB – short of breath • TKO – to keep open • Y/O – years old • V.S. – vital signs • w/o – without • WNL – within normal limits Revised: August 2007

  15. SOAP Report Writing Revised: August 2007

  16. Why do we document patient care? • Information for hospital staff • Quality assurance or statistics • Legal record of our observations and care which could later be used in a courtroom • Professional accountability. Revised: August 2007

  17. Tips for Documentation • Be honest, complete and accurate • Reports should be written objectively. • Legible handwriting • Correct spelling • Use of standardized abbreviations • Never falsify information Revised: August 2007

  18. Tips for DocumentationObjectivity • Do not write your opinions or judgments about the patient • Be careful to avoid terminology which could be construed as slander/libel like drunk, alcoholic, druggie. • Avoid placing blame for any potential litigious circumstances, Instead site direct quotes of the patient and witnesses. Revised: August 2007

  19. Documentation Format • S – Subjective • O – Objective • A – Assessment • P – Plan Revised: August 2007

  20. SubjectiveWhat was told to you • Describe the patient like age and gender. • Chief complaint. • What the patient tells you in description • SAMPLE questions • What other people at the scene tell you like other responders, witnesses, or police. Revised: August 2007

  21. ObjectiveWhat you see, hear, and feel. • Initial impression of the patient like location and position. • General observations and other noteworthy information such as environmental conditions or patient behavior • Vital signs and level of consciousness • Physical exam findings • Head to toe Revised: August 2007

  22. AssessmentYour Diagnosis • Diagnostic conclusion(s) based on the patient's chief complaint and your physical exam findings. • Qualify each with "possible" or "rule out.“ • May have more than one diagnosis Revised: August 2007

  23. Plan What you did • Should be chronological • What was done prior to your arrival • What was done for the patient • How patient responded to the treatment • How care was discontinued or transferred • Patient’s condition at departure Revised: August 2007

  24. Specific Documentation Concerns Revised: August 2007

  25. Specific Documentation ConsiderationsCrime Scene • Don't walk through pools of blood or contaminate evidence • Reports on these cases should be prepared with additional care for you may have to testify in court • Document statements from the patient very precisely • Document “chain of evidence” when turning over evidence Revised: August 2007

  26. Specific Documentation ConsiderationsHomicide • Wait for police to secure scene • Advise an officer of entering scene • Avoid tunnel vision and take a wide view of the scene as you enter • Keep the number of people entering the crime scene to a minimum • Leave all disposable equipment on the victim and document what procedures you did Revised: August 2007

  27. Specific Documentation ConsiderationsChild and Elderly Abuse • With emotional challenges it is important to maintain professional demeanor • Note in report all unusual marks, bruising, burns, healing wounds, evidence of dehydration, or any abnormalities noted on exam. • Contact abuse hotline and note on report Revised: August 2007

  28. References • Stevens, Kay, and Garber, Debra. Introduction to Clinical Allied Healthcare. 2nd ed. Clifton Park, New York: Thomson Delmar Learning, 1996. • Maggiore, Ann and Gurchiek, David. How to document the unthinkable. JEMS. Revised: August 2007

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