There will be alot to fill here, because my world is spinning. But its a good spin, one that is delightful and doesn't leave you with that nauseous feeling when you step off.
Well first I want to say how delighted I am that Iv'e passed all my comps thus far. Its encouraging because when I entered the program I knew I could handle the academia but I was worried about the clinical aspect. Now that I have actually had hands on experience with the instruments Iv'e flipped and am much more comfortable with the clinical setting. Infact I believe the clinical side of Dental Hygiene is my strong point. The next comp is Soap Notes! This is where I feel I need the most improvement. Even though we have been doing it since day one, I still have to flip back to the prior notes to remember what I need to put in S O A P. Now I have the basic idea. S is subjective: race, age, sex, Chief complaint (which you have the patient sign), Allergies, Medications, Hospitalizations. I won't go on because its very detailed, but its the A and the P I get mixed up. This is the part you are more than welcome to comment and reply to, it would be appreciated. A: Long term and short term goals- and what you found in the mouth? And then P: What you did today; and what you will do on the next appointments. To me A is a repeat of EOE and IOE and P is a repeat of A. So does anyone have a well thought out way to differentiate the two? That would be lovely!
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I have to agree that soap notes are very detailed. Infact I use my notes the entire clinic session to make sure I am on the right track. My notes from Mrs. I's lecture on soap notes have been more helpful than the actual powerpoint. She Shated that the A: Assesment is the Evaluation. THis is the Problem statmet: where the Perio Classification, location and severity is placed. The impression of why the problem exist and the LTG/STG. The P is how you plan to achieve the goals, treatment and hygiene instructions. :)
ReplyDeletePersonally I would like to re-invent the soap notes thing and come up with a better way to document. I agree with you and I still have issues with them. I think because we started off with the written chart and moved to Axium that I gets confusing because there is so much to do in Axium. I think the part about long term and short term goals does not pertain to every patient. I would like to leave that part blank at times because I am just being repetative it seems. Maybe one day we can re-invent these SOAP notes! Axium is still my arch enemy right now. I do not like it. I feel like it takes forever to accomplish anything and the SOAP notes are very repetative with all of the other forms we fill out such as: medical history, physical exam etc. My hope is next semester we can have all the glitches fixed and things can run smoother and quicker with Axium. That would be fantatstic!
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