Self Assessment Round 3

MiniCat EBM

Hospital HP 01302018

When comparing the two H&P, I have noticed that the second one is more inclusive. For example, the first H&P is lacking assessment and plan, and also differential diagnosis. The physical exam of the first H&P is only done up to the lung and chest exam, while the physical exam of the second H&P is done up to the abdominal exam. My history-taking has improved in collecting a more detailed history from the patients. In my first H&P, I have only included any known drug allergies without mentioning other allergies such as environmental and food. In my second H&P, allergies as well as the patient’s reaction are included. It also includes any referral sources that the patient has. In terms of writing my HPI and fulfilling the questions for OLD CARTS, my first one is not as completed as the second one. Some of the important information such as frequency of dark stools and burning stomach are not mentioned in the first HPI. While for the second HPI, the onset and duration of the chief complaint are being elicited. My strongest area in performing a physical exam is being able to complete the full physical in time. However, my weakness is having difficulties completing the physical exam without missing any parts. Sometimes I will forget to check a part of the cranial nerve, or check for pulses. I will also need to work on my percussion skills. When starting the clinical year, I think it is important for me to get stronger at doing a focused exam. It will be difficult to do a full physical exam on every patient that we have seen. We will need to do the specific exams for the systems that are related to the patient’s chief complaint.

TO: Melinda Katz, Queens Borough President

FROM: Lingyi Mei

DATE: 1/19/2018

Re: Reducing Early Childhood Tooth Decay in Queens, NY

Statement of Issue:

Tooth Decay is largely preventable, yet it still remains the most common chronic illness for children. Untreated tooth decay can cause pain and infections that may lead to missed school days, poor appearance, decreased self-esteem and even death. Nearly half of all children entering kindergarten have had at least one cavity and three-quarters have untreated cavities. In the U.S, 9 million children lack health insurance, and more than twice that number lack access to oral health services. The percentage of children with untreated tooth decay is twice as high for those from low-income families compared with children from higher-income families. This is implying that the current oral health care system is not adequately addressing the needs of children with the highest risk for poor oral health.

States often use periodicity schedules that do not align with updated professional guidelines. This will limit the frequency of dental visits and preventive services, despite a child’s level of risk. Periodicity schedules may imply limits for patients and providers.

Socioeconomic forces that place these children at risk of untreated dental decay. Children living in poverty do not visit the dentist as regularly. Besides health insurance coverage, barriers such as provider office location and whether a practice accepts Medicaid insurance could impact utilization.

Connection between nutrition and oral health condition. Food insecure families tend to have less control over food selection. The nutritional scale in lower income communities is leading towards more cariogenic food.

Poor oral health status lead to problems with learning and other medical conditions. Children were 3 times more likely than their peers to miss school as a result of dental pains. Health issues that are caused by poor oral health include cardiovascular disease, respiratory infections, renal disease, diabetes, etc.

Policy Options:

• State dental periodicity schedules should serve as the minimum recommended frequency for preventive oral health visits, rather than the maximum allowable frequency of preventive oral health visits. States should also consult with professional dental organizations in developing their dental periodicity schedules.
• Advantages: This will allow the building in the flexibility for providers to follow clinical guidelines, which will be directed at providing evidence-based approaches to prevention. Adherence to professionally recommended best oral health practices will meet the medical and dental needs of the children. Children’s access of dental health care will not be limited by the dental periodicity schedule.
• Disadvantages: expanding the frequency of preventive care will increase the cost for preventive care.

• Explore opportunities to invest in fluoride tooth brushing programs through early childhood education programs. Asking the Centers for Medicare and Medicaid Services to allow the use of Medicaid administrative dollars to support investment in community water fluoridation efforts.
• Advantages: Fluoride combats tooth decay and prevents the acid produced by the bacteria in plaque from dissolving, or demineralizing tooth enamel.  It can reverse low levels of tooth decay and thus prevent new cavities from forming.  Children with at least 4 fluoride varnish application between ages 6 months and 35 months experienced the least decay.
• Disadvantages: People have raised questions about the safety and effectiveness of water fluoridation.  Some researches have shown a small link between fluoride consumption and osteosarcoma, a rare form of bone cancer.
• State should reimburse medical providers for performing oral health risk assessments, providing anticipatory guidance, and applying preventive fluoride varnish to children. Also offering primary care physicians access to a network of referring dentist.
• Advantages: To reduce the incidence of caries and improve children’s access to preventive oral health care. Medical providers will be more willing to perform oral health assessment on children when there is an effective referral structure to ensure patient access on follow up dental care.  Dental preventive care is less expensive than inpatient dental care for caries-related conditions.
• Disadvantages: Will be relying on other health care providers to perform oral screenings in children, rather than dentists.

Policy Recommendations:

Dental disease can impact all aspects of children’s lives, from their nutrition to their educational performance and self-esteem.  States have an important role to play in the adoption and implementation of strategies to promote the use of oral health care among children enrolled in Medicaid. Improving state Medicaid program performance through policy changes will lead to enhanced oral health care access and utilization for children.  The goal of the new policies will be focused on increasing dental preventive care and avoiding expensive inpatient dental care for caries-related conditions in the future.

Reference:

• http://www.ncsl.org/research/health/childrens-oral-health-policy-issues-overview.aspx
• https://www.cdc.gov/oralhealth/children_adults/child.htm
• https://www.webmd.com/oral-health/features/oral-health-the-mouth-body-connection#1
• http://www.aapd.org/policy_center/state_dental_periodicity_schedules/
• https://ilikemyteeth.org/a-perfect-smile-comes-at-a-cost-how-poverty-and-food-insecurity-cement-disparities-in-oral-health/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222359/
• https://www.medicaid.gov/medicaid/benefits/downloads/keep-kids-smiling.pdf
• http://kidshealth.org/en/parents/fluoride-water.html
• https://www.cancer.org/cancer/cancer-causes/water-fluoridation-and-cancer-risk.html

Breast Cancer Prevention for Korean American Women in Flushing, Queens

1.         Scope of the Problem

•             Breast cancer is the most commonly occurring cancer in Korean American women.  They consistently have reported relatively low rates of breast cancer screening, which indicates they may be at high risk for cancer mortality and morbidity because of delayed diagnosis.

•             Mammogram screening rate in Korean American women age 65 and older: 12% to 69% had ever had a mammogram, and 7% to 35% were estimated to have had a mammogram in the preceding year.

•             Lower rates of clinical breast examination and breast self-examination were also reported.

•             Older Korean American women were less likely to be married and employed, they were also less educated and had lower incomes. A significantly higher proportion of older Korean American women reported that they could not speak English at all or only a little.

•             Study shows that lack of significance and lack of knowledge are significant barriers to having a mammogram.

•             Different health beliefs also contributed to their lower screening rates, such as lack of belief in benefits of mammography.

•             Other barriers to mammogram: fear of finding something wrong, fear of embarrassment or lack of modesty, not knowing where to go for screening, believing that mammography is only needed when symptoms are presented.

•             Mammography screening is the only screening method that has proven to be effective, which reduce breast cancer mortality by around 20%.

2.         Planning.

• Identify changes:

• Promote breast cancer awareness in Flushing, Queens, where many Korean American immigrants resided. Fliers and brochures with pictures in Korean will be given out.  This will be needed to take care of the residents that do not speak English.
• Encourage primary care physicians in the area to stay up-to-date and adhere to screening guideline. Motivational interviewing will be use to find the internal motivation they need to change their behavior. PCPs will be offering culturally sensitive educational materials and consider patients’ literacy levels.  Medical translators should be provided if the physician is not able to communicate in Korean. Offer flexible mammography screening hours such as evenings and Saturdays.
• Emphasize importance of having a mammogram and high incidence rates of breast cancer in older age.  It is also necessary even when one does not have symptoms. Emphasize the benefits such as detect early, live longer.  Address negatives and outdated beliefs about cancer and cancer treatment.
• Mail reminders to patients that are overdue for a mammogram.
• Use flu season as an opportunity to promote screenings, offer mammography appointments and brochures.
• Culturally tailored education, outreach program and intervention.  Establish programs in the area to assist minorities with translating, scheduling for doctor’s appointment, educating breast cancer and promoting screening, giving out brochures and booklets, applying for insurance coverage, provide financial assistance/transportation.
• These changes will be focused on behavioral changes because different health belief and cultural disparities are the main barriers to having a mammography. Promoting and educating will raise awareness of breast cancer in Korean American women, and thus will lead to higher screening rate.

• Stakeholder

• Will include legislators, gynecologists/PCPs, women right organizations, Minority Rights Group, Korean American women, local and community educators, imaging centers
• Stakeholders will accept this program because breast cancer should be highly attentive in minority group. However, white women have the highest percentages of receiving a mammography, while other minority ethic groups have lower percentages. Korean American women have a lower screening percentage compared to Asian women as a whole and the state average.  Additional effort and attention should be given to this minority group because cultural difference should not impact the access and quality of care. Finding breast cancer early reduces risk of dying from the disease by 20-30% or more.  Increasing breast cancer screening rate and awareness of the benefit can save lives by finding breast cancer as early as possible.
• The program/plan will be funded by state and local funds, county and city revenues, Prevention and Public Health Fund.

• I believe my program will be feasible in the long-run because cancer rate of the minority group is an important public health topic to receive funding and support from the related foundations and funding agencies, as well as state and local public health funding.  Screening tests should not be available to specific race or populations.  This program will possibly influence the awareness of screening tests for other types of disease and cancer as well.
• To obtain important information within the population, surveys and qualitative research will be done in both patients and providers.  Surveys questions that include the knowledge of breast cancer screening will be asked to the patients before and after the intervention. For providers, they will be asked about the support and assistance that they are offering to the patients, and the effect on the rate of breast cancer screening and patient outcome and care.

3.         Development & Dissemination of the Intervention

• The goal of this program is to promote breast cancer screening in Korean American and increase awareness by educating breast cancer in a culturally sensitive direction.  Since Korean American women reported a low screening rate, we would want to focus our intervention at an area (Flushing, Queens) with excessive amount of Korean American women. It is necessary to monitor the rate of breast cancer screening and the incidence of breast cancer.  Surveys will be given out to the patients to measure their awareness of breast cancer.
• We would be collecting data in patients within several domains: knowledge of symptom, confidence/skills/behavior in relation to detecting a breast change, anticipated delay in contacting the doctor, knowledge of risk factors, knowledge of breast screening programs, frequency of breast checking, age-related risks.  This will help to measure the level of patient awareness on breast cancer. The score for the level of awareness will be increased after a promoting intervention.
• Monthly group education will be established in the neighborhood to encourage and motivate patients to seek recommended screening. It will be conducted by a health care professional (with a translator/interpreter if needed) who use presentations or other teaching aids in a lecture or interactive format, and often incorporate role modeling or other methods.  The purpose of educating the Korean American women is to ensure that they understand the risks of cancer.  Group education will also emphasize the fact every woman in this class will need to have mammogram and they shouldn’t feel embarrassed to have a breast exam.
• Primary care providers should be aware of cultural sensitivity. Translating/interpreting services should be available to the patients.  They should also ensure that adequate amount of time of the annual check-up appointment (or flu-shot appointment) is spent on patient counseling and education.  Providers should also offer flexible hours and mail mammography reminders to patients.
• The program will also have hotline service. Multilingual representatives are available Monday to Friday 9AM to 5PM to assist the patients in scheduling doctor appointments, applying for low-income health insurance coverage, answering questions, providing instructions of where to go for screening, planning for transportation, and even providing a medical translator/interpreter for the doctor’s appointment etc. These supports will increase the access of care in the hope of increase breast screening and patient outcome.
• Every week, brochures/booklets/posters/fact sheets with the applicable information on breast cancer will be mailed and emailed to the patients.  Materials included will be symptoms, screening and recommendation, prevention and promotion, breast self- examination, risk factors, and other relevant facts.

4.         Evaluation & Maintenance

• Semiannual Evaluations: Data will be collected overtime, from the start of the program and after program implementation. It is important to consider the program’s focus, the needs of the audience or funders, and the time frame and training available for meeting program goals. Population health measures may be also used in evaluation. Patients data will include demographic data, biological markers, health status, medical history and knowledge. Program process measures will include the level of awareness, program activities, patient outcome, screening rates, incidence of breast cancer, access of care, policies and implementations, types of resources and contributions provided by stakeholder groups, perceived health status, number of people aware of program messaging and intend to take action
• Future Improvement: if the interventions are unsuccessful, future improvement and adjustment will be made based on the data collection. If the breast cancer screening rate is not increasing within expectation or the incidence rate is increasing, further promotion and education on genetic counseling and testing for BRCA 1 and BRCA 2 mutation may need to be implemented. This will allow people to learn if their breast cancer is due an inherited gene mutation.  In addition, more future research might need to be funded to find out the reasons for the minorities to deny screening.
• Program Maintenance: The sources of funding will mainly be local and state, but also minority group foundation, and other funding agencies. There will be continuation of data collection to monitor the program process and to suggest future adjustment.

Reference:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3089419/
• https://link.springer.com/article/10.1007/s10900-016-0258-7
• https://www.stratishealth.org/documents/8-ways-increase-breast-cancer-screening-rates.pdf
• https://www.cancerresearchuk.org/sites/default/files/health_professional_breast_cam_toolkit_09.02.11.pdf
• https://www.ncbi.nlm.nih.gov/pubmed/20335018
• https://www.ruralhealthinfo.org/community-health/health-promotion/4/measures-for-evaluating
• https://www.webmd.com/breast-cancer/guide/what-causes-breast-cancer
• https://www.health.ny.gov/funding/

Hospital HP 11072017

Juana Negron

Immunizations

Flu shoot, Td Booster,

Screening

Alcohol misuse, depression, hypertension, obesity, tobacco use and cessation, HIV infection, intimate partner violence, PAP smear, Lipid disorder, Abnormal glucose/diabetes, Hep C virus infection, colorectal cancer (colonoscopy), breast cancer(mammogram)

Health Promotion/Disease Prevention Concerns – please address all that are relevant for this patient:

• Injury Prevention

Traffic Safety, Burn Prevention, Falls Prevention, Choking Prevention, Safe sleep environment, Poisoning prevention, firearm safety, Drowning/water safety

• Diet
  • Please identify any relevant dietary issues for this patient

Cooked unhealthy food, tried to loose weight but failed, tried several kinds of diet but never had success

• While thinking about diet, consider any specific health issues this patient has and how diet should be modified to address them (you may have to look some up since you haven’t studied them yet)

Borderline hypertension, obesity, smoker, anxiety, asthma

• Based on your assessment, outline a plan to address any dietary modifications you think are indicated for this patient

For smoking, eating 3 servings of fruits and vegetables per day and drink green/black tea helps protect themselves from lung cancer.

For asthma, add vitamin D-rich food, such as milk and egg. It can reduce number of asthma attacks.  Beta-carotene-rich vegetables, such as carrots and leafy greens, and also magnesium-rich foods, such as spinach and pumpkin seeds can provide a better quality of life for asthma patients.  Increasing magnesium levels can also have higher lung flow and volume.

Foods that help to fight inflammation for arthritis pain are broccoli, Brussel sprouts, cabbage, fatty fish, garlic, tart cherries, and Vitamin-C.

For anxiety, don’t skip meals because it will result in drops in blood sugar that cause the patient to feel anxious. A diet rich in whole grain, vegetables, and fruits is a healthier option than eating a lot of simple carbohydrates found in processed food.

For hypertension, follow the DASH diet, which stands for Dietary Approaches to Stop Hypertension.  It is a diet rich in fruits, vegetables, low fat or nonfat dairy, which is also beneficial to weight loss.  For breakfast, the patient can start with 1 whole-wheat bagel with 2 tablespoons of peanut butter with no salts, 1 medium orange, 1 cup fat-free milk, decaffeinated coffee.  For lunch, the patient can have spinach salad made with 4 cups of spinach leaves, a sliced per, ½ cup of mandarin orange, 1/3 cup slivered almonds, 2 tablespoons red wine vinaigrette, 12 reduced-sodium wheat crackers, and 1 cup fat-free milk.  For dinner, the patient can have a 3 oz. cooked herb-crusted baked cod, 1/2 cup brown rice pilaf with vegetables, ½ cup fresh green beans, steamed, 1 small sourdough roll, 2 teaspoons olive oil, 1 cup fresh berries with chopped mint, and herbal iced tea.  For snack (anytime of the day), 1 cup fat-free, low calorie yogurt, and 4 vanilla wafers.

• Exercise
  • Determine whether this patient is likely to be getting adequate exercise as per current guidelines

The patient is not doing any exercise other than her job activity and walking her dogs, she is not meeting the current exercise guideline.

• If the patient is not meeting current guidelines, please suggest a plan to meet them that is specific to this patient’s goals and concerns

Activities that involve short, intermittent periods of exertion, such as volleyball, gymnastics, baseball, and wrestling, are generally well tolerated by people with symptoms of asthma.  Swimming and yoga are also well tolerated by people with asthma.  Use pre-exercise asthma medicine before beginning exercise.  Perform warm-up exercise, and maintain an appropriate cool-down period after exercise.  When it is cold outside, use a mask to cover nose and mouth when exercise. Patient should start slowly and do low intensity exercise.  Don’t start off with high intensity exercise due to increase risk when suddenly become much more active than normal.  Start with 30 minutes of swimming for 4 to 5 days in a week.  Then follow up every month to check on progress.

• Harm Reduction

Smoking and diet are already discussed in other sections.  I will still discuss about the patient’s job at Ground Zero because that is where she developed asthma.  We will discuss the precautions that she will need to take when working in harsh environment.  The patient also has anxiety because she is concerned about her landlord selling the building, and also her son’s financial difficulties.  She will need to be counseled on that.

Brief Intervention

• Obesity

I will use the 5As for obesity.  They are Ask, Advice, Access, Agree, Arrange/Assist.  For Ask, I will ask permission to discuss weight and explore readiness for change. I will ask question such as “Can we discuss your weight and the effects it may be having on your health?”  For Assess, I will assess health status, obesity indicators, and explore causes of weight gain.  I will ask if the patient can tell me about her past weight gain and loss, her daily diet and physical activity, family history of overweight/obesity, and any medical conditions.  For Advice, I will advice patient of health risks of obesity, benefits of modest weight loss, need for long term management, and treatment options.  I will ask “What do you know about the effects of overweight and obesity in health risks?”  For Agree, the patient and I will agree on appropriateness of weight loss, expectations, targets, behavioral changes, and treatment plan details.  I will ask “Is this a good time for you to pursue weight loss? What is your expected weight?”  For Arrange/Assist, I will assist the patient in identifying and addressing barriers, provide resources, referring, and arranging follow-up.  I will ask “Would you like me to refer you to someone who can help you with diet and exercise?”

• Smoking Cessation

I will use the 5A’s for smoking cessation. They are Ask, Advise, Access, Agree, Arrange/Assist.  For Ask, I will ask the patient “are you currently smoking?  How ready are you to start smoking cessation on a scale of 1 to 10?” and we will explore the patient’s readiness to change.  For Advice, I will ask permission to give advice and information.  I will talk about the health risks and benefit of smoking, including long and short term.   I will advise medications and other tools to help. I will ask “Can I give you advice on how to start with smoking cessation? Do you know what kind of risks are involved with smoking? Can I tell you some short and long term benefits?”  For Access, I will access the patient’s health status and addiction to nicotine using the heavy smoking index (HSI).  I will ask “How many cigarettes, on average, do you smoke? How soon after waking do you smoke your first cigarette?”  For Agree, I will discuss and set a quitting date with the patient.  We will also agree on what medication will be used and when to start them.  We will also identify behavioral changes to be made and formalize a plan together.  “When would you like to start quitting? What do you want to start the medication that we’ve discussed about?” For Arrange/Assist, I will provide prescription, refer patient to support group, internet, and other regular check-in option. Follow-up will be arranged as well. I will ask “Would you like me to refer you to any one that can help you with smoking cessation?” There are also 5 R’s to motivate the patient: Relevance, Risks, Rewards, Roadblocks, and Repeat.  Relevance is the reason that push the patient to quit smoking, such as pregnancy, family member’s health, and employment. Risks is to advise the effects of continued smoking. Rewards is the benefit of quitting such as better health and huge saving.  Roadblocks is to explain potential barriers such as other smokers around you, past history of unsuccessful attempts, and weight gain.  Repeat is to repeat relevance, risks, rewards, and roadblocks.

• Substance Use

Not applicable to the patient.

Although there are a list of issues that should be addressed, the most important issue that should be considered now is the patient’s BMI.  The patient has a BMI of 30.9 and a waist circumference of 40 in are considered as obese. Obesity can lead to heart disease, stroke, high blood pressure, diabetes, osteoarthritis, asthma, and breathing problems.  Once the patient drops her BMI, she will be less risk of her current health issues such as anxiety, asthma, and borderline high blood pressure.  Once the patient starts following the diet and exercise plan, she will be healthier with less chance of having other diseases.

Reference:

https://www.healthline.com/health/asthma/asthma-diet

http://newsroom.ucla.edu/releases/fruits-vegetables-and-teas-may-51210

http://blog.arthritis.org/living-with-arthritis/diet-foods-arthritis-pain/

https://www.health.harvard.edu/blog/nutritional-strategies-to-ease-anxiety-201604139441

https://www.webmd.com/asthma/guide/exercising-asthma#2

The ethical framework that I choose for guidance of my clinical practice is mainly focused on how to act in the patient’s best interest by managing effective physician-patient communication, and how to encourage patient’s right by allowing autonomous decisions.

I have chosen to become a PA because I want to be a bridge between patients and the health care team.  From my previous experience of working in clinical office, there are actually a lot of patients who are not able to speak a word or two in English. Even if they are suffering from severe pain during the night, they still refuse to go to the emergency room and rather wait to see their primary care physician the next morning.  They are frightened to communicate with any physicians that doesn’t speak their languages. Patient should not be shut down from the health care system due to communication barrier. They should have to right to choose how they want to be treated without worrying about physician-patient communication.  I want to introduce a comfortable environment for patients so that they can trust and rely on the healthcare system.

The most important aspects of clinical practice are effective communication and respecting patient’s right.  Communication plays an important role in every step of treatment and diagnoses.  Not only that we have to communicate with other colleagues in order to promote team work, we also have to communicate with patients to get their history.  Effective communication with patients will show emotional support and caring for their health status.  The effort spent on communication with patients will also increase the quality of care. Patient’s right is also significant because they should understand the impact of every medical decision on their health conditions. They have the right to accept or reject any suggested treatment by physicians, instead of being forced to sign any document to agree with the procedures.  Physician’s suggestion should not override the patient’s preference.

Two ethical principles that will play the strongest role in my ethical decision-making in clinical practice are beneficence and autonomy.  Beneficence is action that is done to benefit the patients. (Yeo, 2010) Any medical decisions should be made in the obligation to remove harm and to help patients.  Physicians can also simply produce goods when acting in patient’s best interests.  Autonomy is patient’s right to make autonomous decisions and choices regarding to one’s own life.  It comprised of free action, effective deliberation, authenticity, and moral reflection.  (Yeo, 2010) Free action is being able to do what one wishes to do, and not being forced to what one does not want to do.  Effective deliberation is making a choice through a process of reasoning and understanding of the outcome.  Authenticity is when the given choice of action is consistent with one’s expressed values and character.  Moral reflection is self-examination and consistency with choice.

Effective physician-patient communication in clinical practice is supported by the principle of beneficence.  Communication includes the ability to gather information in order to make accurate diagnosis, to give instructions, and to build caring relationships with patients.  Making accurate diagnosis and giving therapeutic instructions are preventing harm from the patient because the patient can be cured without further complications of the disease.  Building a caring relationship with patient is also acting in patient’s best interests by ensuring that the patient is receiving the best possible care for improving health conditions.  These elements of communication are promoting quality patient care and inhibiting medical errors.  Respecting the patient’s right in clinical practice is supported by the principle of autonomy.  For example, informed consent shows significance in the right to self-determined.  Informed consent means more than a plain signature.  Patients are allowed to have free action in choosing the care they want to have.  They need effective deliberation, as in decision-making capacity, to understand the treatment options and outcomes in order to rationally decide.  This informative discussion and ongoing process is allowing the patient to receive adequate information regarding his health status in helping him to decide upon treatment options. Therefore, they are signing the informed consent with understanding of the outcomes and treatment, rather than being forced to sign without knowing the possible complications.

In conclusion, communication is significant because it benefits patients by increasing the quality of care and reducing the chance of potential medical errors.  Patient’s right is significant because it is the self-determination to make autonomous decision without external pressures.  I will be using these principles as a guidance for my clinical practice.

Reference:

1. Yeo, Michael et al. (2010). Beneficence. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics.[3rd edition] Ontario: Broadview Press, pp. 103-116.
2. Yeo, M et al. (2010). Autonomy[selections]. In M Yeo et al. (eds.).Concepts and Cases in Nursing [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.

https://www.youtube.com/watch?v=amCMf6gsOJ4

Writing a SOAP note for the first time is definitely a challenge for me, but I have also learned more about the topic as well.  I have also realized that the SOAP note plays an important role when it comes to effective communication in the medical team.  We have to choose what we think are the important information to help with the diagnose and treatment, and then write them down in the S.O.A.P order, which stands for subjective, objective, assessment, and plan, respectively.  The other health care providers will rely on these relevant informations to continue the care for the patient. Writing a specific and detailed SOAP note can also help to prevent medical errors as well.  The most challenging parts of writing a SOAP note are the A (Assessment) and the P (Plan).  It is difficult to come up with differential diagnoses and plan when we don’t have much clinical knowledge as a first year student.