Please help with objective . . .
Posted By: Thank you! (sm) on 2006-07-25
In Reply to:
Subject: Please help with objective . . .
The wound has been cleaned by the nurse, and it looks very good. s/l Pride flesh is starting to form.
TIA for any suggestions!
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Objective portion
Subject: Objective portion
does this make sense to anyone
GU and rectum s/l farum are rectal sphincter muscle tone
a few hints for you - when doing the objective
Subject: a few hints for you - when doing the objective
findings, when doc says, for instance, "In general, the patient is..." you are putting that under the "general" subheading, so you don't need to repeat the "in general" part - meaning it would just be GENERAL: The patient is....
same with the skin exam that you have there - if doc is saying "skin is warm and dry," and you are putting it under the "skin" subheading, it should just be "SKIN: Warm and dry" ...and so on.
also, in the HEENT section, it should be "sclerae" and "conjunctivae" - doc is referring to the plural form here.
Does that make sense? This is the way it's usually done, but you'll need to follow the instructions you've been given, of course.
It's just under and Objective/General section
Subject: It's just under and Objective/General section
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though. 
OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
Subject: OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
diagnosis: Cerumen impaction.
Objective: Head is held straight with no s/l "lift or lisp"
Subject: Objective: Head is held straight with no s/l "lift or lisp"
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