Yuav Ua Li Cas Tsim SOAP Sau Ntawv (nrog Duab)

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Yuav Ua Li Cas Tsim SOAP Sau Ntawv (nrog Duab)
Yuav Ua Li Cas Tsim SOAP Sau Ntawv (nrog Duab)

Video: Yuav Ua Li Cas Tsim SOAP Sau Ntawv (nrog Duab)

Video: Yuav Ua Li Cas Tsim SOAP Sau Ntawv (nrog Duab)
Video: Zoo Siab Nrog Koj - Paj Tsua Thoj [ Official MV ] Nkauj Tawm Tshiab 2022 2024, Plaub Hlis Ntuj
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Qhov tseeb, SOAP cov ntaub ntawv yog cov cuab yeej siv los ntawm cov neeg ua haujlwm noj qab haus huv los sau cov ntaub ntawv kho mob thiab qhia rau lwm tus neeg kho mob, yog xav tau. Tshwj xeeb, muaj ntau ntu uas yuav tsum tau sau rau hauv SOAP cov ntaub ntawv, uas yog Cov Qauv (S), Lub Hom Phiaj (O), Kev Ntsuam Xyuas (A), thiab Kev Npaj (P) ntu. Vim tias tom qab SOAP cov ntaub ntawv yuav raug xa los ntawm ib tus kws tshaj lij kho mob mus rau lwm tus, nco ntsoov tias koj siv cov lus meej thiab ncaj ncaj thaum sau nws. Los ntawm kev muab cov ntaub ntawv muaj tseeb hais txog tus neeg mob kuaj mob thiab kev noj qab haus huv, koj yuav tsis ntseeg tias yuav pab tus neeg mob kom tau txais kev kho mob zoo tshaj plaws!

Kauj ruam

Ntu 1 ntawm 5: Sau rau hauv Ntu Kev Kawm

Sau Ntawv Ceeb Toom Kauj Ruam 1
Sau Ntawv Ceeb Toom Kauj Ruam 1

Kauj Ruam 1. Nug tus neeg mob cov tsos mob

Nug tus neeg mob kom qhia lawv cov kev tsis txaus siab yog li koj tuaj yeem txheeb xyuas cov tsos mob uas lawv tau ntsib. Khawb cov ntaub ntawv hais txog tus neeg mob tus thawj coj tsis txaus siab thiab muab nws tso rau saum SOAP cov ntaub ntawv. Tus neeg mob qhov kev tsis txaus siab lossis Tus Thawj Fwm Tsis Txaus Siab (CC) tuaj yeem pab lwm tus neeg ua haujlwm kho mob los tshuaj xyuas tus txheej txheem ntawm tus neeg mob qhov xwm txheej tau sau tseg hauv SOAP cov ntaub ntawv.

  • Hauv ntu Kev Kawm ntawm SOAP sau tseg, koj yuav tsum sau ntau yam tsos mob uas tus neeg mob tau ntsib thiab txhua yam kev kho mob uas tus neeg mob tau ua.
  • Qee qhov teeb meem kev kho mob ib txwm muaj los ntawm cov neeg mob yog mob hauv siab, tsis qab los noj mov, thiab ua tsis taus pa.
  • Yog tias koj xav tau, koj kuj tseem tuaj yeem nug tus neeg mob tus khub lossis txheeb ze rau cov ntaub ntawv ntxiv.

Tswv yim:

Yog tias tus neeg mob yws ntawm ntau cov tsos mob ib zaug, ua tib zoo mloog cov tsos mob uas muaj cov lus piav qhia ntxaws tshaj plaws los txheeb xyuas lawv thawj qhov kev tsis txaus siab.

Sau Daim Npav Ceeb Toom Kauj Ruam 2
Sau Daim Npav Ceeb Toom Kauj Ruam 2

Kauj Ruam 2. Siv cov ntawv luv OLDCHARTS kom tau txais cov ntaub ntawv muaj txiaj ntsig los ntawm cov neeg mob

Hauv ntiaj teb kev kho mob thoob ntiaj teb, OLDCHARTS yog txheej txheem mnemonic siv los ntawm cov kws kho mob kom nco qab cov lus nug uas yuav tsum tau nug ntawm cov neeg mob. Tom qab nug cov lus nug tseem ceeb hauv OLDCHARTS, sau tus neeg mob cov lus teb kom SOAP cov ntaub ntawv tuaj yeem tswj tau zoo dua. Tshwj xeeb, OLDCHARTS yog cov ntawv luv rau:

  • Pib: Thaum twg tus neeg mob tau hnov thawj qhov kev tsis txaus siab?
  • Qhov chaw: Tus neeg mob tus thawj coj tsis txaus siab nyob qhov twg?
  • Ntev: Ntev npaum li cas tus neeg mob xav tias yog tus tsis txaus siab?
  • Tus Cwj Pwm: Tus neeg mob yuav piav qhia nws qhov kev tsis txaus siab li cas?
  • Txhim kho lossis ua rau hnyav ntxiv: Puas muaj cov xwm txheej uas txhim kho lossis ua rau tus neeg mob lub luag haujlwm tsis txaus siab?
  • Kev Tshaj Tawm: Puas yog tus neeg mob qhov kev tsis txaus siab tshwm sim tsuas yog nyob ntawm ib kis lossis lawv tshwm sim tsis tu ncua?
  • Cov qauv ib ntus: Puas yog thawj qhov kev tsis txaus siab tshwm sim nyob rau lub sijhawm tshwj xeeb?
  • Qhov hnyav: Ntawm qhov ntsuas ntawm 1-10 (10 yog qhov phem tshaj), tus neeg mob tus thawj coj tsis txaus siab yog dab tsi?
Sau Ntawv Ceeb Toom Kauj Ruam 3
Sau Ntawv Ceeb Toom Kauj Ruam 3

Kauj Ruam 3. Suav nrog tus neeg mob tsev neeg keeb kwm thiab/lossis keeb kwm kev kho mob

Nug seb puas muaj keeb kwm kho mob lossis phais mob hauv tus neeg mob tsev neeg. Yog li, suav nrog hnub tim tus neeg mob kuaj mob thiab/lossis lub npe ntawm tus kws kho mob uas ua cov txheej txheem kev phais. Tom qab ntawd, tseem txheeb xyuas seb tus neeg mob tsev neeg muaj qhov xwm txheej zoo ib yam los txhawm rau lees paub lossis tshem tawm qhov muaj peev xwm muaj teeb meem caj ces.

Nco ntsoov tias koj tsuas suav nrog cov ntsiab lus uas tseem ceeb rau tus neeg mob. Hauv lwm lo lus, tsis suav nrog tsev neeg keeb kwm kev kho mob ntawm tus neeg mob yog tias cov ntaub ntawv tsis muaj feem cuam tshuam

Sau Ntawv Ceeb Toom Kauj Ruam 4
Sau Ntawv Ceeb Toom Kauj Ruam 4

Kauj Ruam 4. Suav nrog lub npe thiab/lossis hom tshuaj uas tus neeg mob tab tom noj tam sim no

Nug seb puas muaj lossis tsis muaj lub khw muag khoom lossis tshuaj yuav tshuaj uas tau coj los kho lawv cov lus tsis txaus siab. Yog tias muaj, nco ntsoov lub npe tshuaj, qhov tshuaj npaum cas, yuav ua li cas thiaj li siv tshuaj, thiab ntau npaum li cas noj cov tshuaj. Yog tias tus neeg mob noj tshuaj ntau, thov sau lawv ib leeg zuj zus.

Piv txwv li, koj yuav sau: Ibuprofen 200 mg noj qhov ncauj txhua 6 teev rau 3 hnub

Ntu 2 ntawm 5: Ua Lub Hom Phiaj

Sau Ntawv Ceeb Toom Kauj Ruam 5
Sau Ntawv Ceeb Toom Kauj Ruam 5

Kauj Ruam 1. Sau tus neeg mob cov cim tseem ceeb

Txheeb xyuas tus neeg mob lub plawv dhia, ua pa, thiab lub cev kub, tom qab ntawv sau cov txiaj ntsig hauv SOAP cov ntaub ntawv. Yog tias qhov txiaj ntsig siab dua lossis qis dua qhov txwv ib txwm muaj, rov ua ob zaug kom ntseeg tau tias qhov txiaj ntsig tau raug. Nco ntsoov, kev ntsuas cov cim tseem ceeb yuav tsum ua tiav nrog cov txheej txheem raug yog li ntawd lwm tus neeg kho mob tuaj yeem nkag siab tam sim ntawd nrog tsuas yog saib ib zaug.

Cov Hom Phiaj ntu ntawm SOAP cov ntaub ntawv hais txog cov ntaub ntawv koj ntsuas thiab sau los ntawm cov neeg mob

Sau Ntawv Ceeb Toom Kauj Ruam 6
Sau Ntawv Ceeb Toom Kauj Ruam 6

Kauj Ruam 2. Sau cov ntaub ntawv ntau yam uas koj tau txais los ntawm kev tshuaj xyuas lub cev

Tshwj xeeb, tshuaj xyuas thaj tsam ntawm tus neeg mob qhov kev tsis txaus siab kom koj tuaj yeem sau cov txiaj ntsig kev nyab xeeb ntxaws hauv SOAP cov ntaub ntawv. Tsis txhob sau tus neeg mob cov tsos mob, nrhiav lub hom phiaj los ntawm kev tshuaj xyuas lub cev. Thaum kawg, rov qab mus kom paub tseeb tias cov ntsiab lus ntawm koj li SOAP cov ntawv sau tau meej thiab zoo kom tsis txhob cuam tshuam lwm tus neeg kho mob thaum nyeem lawv.

Piv txwv li, tsis txhob sau ntawv "mob plab," koj tuaj yeem sau "mob hauv plab qis thaum thaj chaw raug nias."

Tswv yim:

Nws raug nquahu kom koj sau koj cov kev soj ntsuam ntawm ib daim ntawv cais kom cov ntsiab lus ntawm SOAP cov ntaub ntawv tau zoo thiab tswj tau zoo.

Sau Daim Npav Ceeb Toom Kauj Ruam 7
Sau Daim Npav Ceeb Toom Kauj Ruam 7

Kauj Ruam 3. Sau cov txiaj ntsig ntawm kev kuaj mob tshwj xeeb los ntawm tus neeg mob

Txawm hais tias nws nyob ntawm qhov mob hnyav ntawm qhov tsis txaus siab, koj yuav xav tau kuaj ntxiv, xws li xoo hluav taws xob lossis kuaj tomography (CT scan). Yog tias tus neeg mob kuaj mob ntxiv, nco ntsoov cov txiaj ntsig tau suav nrog hauv SOAP cov ntaub ntawv vim tias nws muaj peev xwm cuam tshuam rau lawv cov txheej txheem kho tom qab.

Txuas cov ntawv ntsuas ntsuas, nrog rau cov duab thiab/lossis cov ntaub ntawv kuaj mob los ntawm chav kuaj kom lwm tus neeg kho mob tuaj yeem pom nws

Ntu 3 ntawm 5: Sau rau ntu Kev Ntsuam Xyuas

Sau Daim Npav Ceeb Toom Kauj Ruam 8
Sau Daim Npav Ceeb Toom Kauj Ruam 8

Kauj Ruam 1. Sau ib qho kev hloov pauv hauv tus neeg mob qhov mob

Yog tias tus neeg mob tau sab laj nrog koj, lossis yog tias lawv tau pom lwm tus kws tshaj lij kho mob, muaj feem tias SOAP cov ntaub ntawv twb muaj lawm uas sau lawv cov keeb kwm kho mob. Koj txoj haujlwm tom ntej yog txhawm rau txheeb xyuas kev hloov pauv ntawm tus neeg mob qhov kev tsis txaus siab kho mob, tom qab ntawd nco ntsoov qhov tsis zoo lossis qhov zoo ntawm tus neeg mob txoj kev kho yav dhau los.

Piv txwv li, yog tias tus neeg mob yav dhau los tau txais daim ntawv tshuaj rau tshuaj tua kab mob, nco ntsoov qhov txo qhov o uas tus neeg mob ntsib

Sau Daim Npav Ceeb Toom Kauj Ruam 9
Sau Daim Npav Ceeb Toom Kauj Ruam 9

Kauj Ruam 2. Sau tus neeg mob cov teeb meem kev kho mob raws li qhov tseem ceeb

Yog tias tus neeg mob muaj ntau qhov kev tsis txaus siab ib zaug, sim sau lawv ua qhov hnyav, nrog qhov tsis txaus siab tshaj plaws nyob rau saum toj ntawm daim ntawv. Yog tias nws nyuaj rau txheeb xyuas qhov teeb meem loj tshaj plaws, sim nug tus neeg mob qhov kev tsis txaus siab uas cuam tshuam rau tus neeg mob tshaj plaws.

Sau Daim Npav Ceeb Toom Kauj Ruam 10
Sau Daim Npav Ceeb Toom Kauj Ruam 10

Kauj Ruam 3. Sau tag nrho cov kev kuaj mob uas koj tau ua

Yog tias koj tswj hwm kom pom ib qho kev kuaj pom meej, sau tam sim ntawd hauv qab tus neeg mob qhov teeb meem. Yog tias txhua qhov teeb meem muaj qhov ua rau sib txawv, sau tag nrho cov laj thawj los saib rau qhov muaj peev xwm txheeb xyuas tau zoo tshaj plaws. Tom qab ntawd, rov nyeem cov ntaub ntawv uas koj tau teev tseg hauv ntu Cov Hom Phiaj thiab Lub Hom Phiaj txhawm rau kwv yees qhov yuav tshwm sim feem ntau.

Yog tias koj muaj teeb meem txheeb xyuas lub hauv paus ua, sim ua cov lus xav kom raug raws li txhua cov ntaub ntawv koj tau pom

Tswv yim:

Yog ua tau, txiav txim ib qho kev kuaj mob uas suav txog ntau yam teeb meem ib zaug. Sau kuj tseem muaj ntau yam mob uas yuav cuam tshuam nrog lwm tus.

Sau Soap Note Step 11
Sau Soap Note Step 11

Kauj Ruam 4. Sau cov laj thawj tom qab kev txiav txim siab ntawm txhua qhov kev kuaj mob, hais txog cov ntaub ntawv suav nrog hauv ntu ntu thiab hom phiaj

Yog tias tus neeg mob muaj ntau qhov kev kuaj mob tib lub sijhawm, tsis txhob hnov qab muab cov ntawv tshwj xeeb yog tias ib qho ntawm kev kuaj mob xav tias tsis sib xws.

Ib txwm muab cov lus piav qhia ntawm txhua qhov kev kuaj mob kom lwm tus kws kho mob paub qhov laj thawj tom qab koj txiav txim siab xaiv txoj kev kho mob tshwj xeeb

Ntu 4 ntawm 5: Sau rau hauv Txoj Kev Npaj

Sau Daim Npav Ceeb Toom Kauj Ruam 12
Sau Daim Npav Ceeb Toom Kauj Ruam 12

Kauj Ruam 1. Suav nrog cov ntaub ntawv hais txog txhua yam kev tshuaj xyuas uas yuav tsum tau ua los ntawm tus neeg mob

Rov nyeem dua qhov kev kuaj mob uas koj tau sau hauv ntu Kev Ntsuam Xyuas ntawm SOAP cov ntaub ntawv thiab txiav txim siab seb puas yuav tsum tau kuaj ntxiv lossis tsis tsim nyog los txheeb xyuas qhov kev kuaj mob. Tshwj xeeb, teev txhua daim ntawv tshuaj xyuas uas sib haum rau txhua qhov kev kuaj mob raws li qhov tseem ceeb.

  • Piv txwv li, koj yuav tsum tau ua cov txheej txheem tomography xam lossis kuaj X-ray txhawm rau txiav txim siab qhov ua rau muaj teeb meem kev kho mob.
  • Suav nrog cov ntaub ntawv hais txog cov kauj ruam uas tus neeg mob xav tau tom qab ua qhov kev tshuaj xyuas tshwj xeeb, ob qho tib si yog tias cov txiaj ntsig tau zoo lossis tsis zoo.
Sau Daim Npav Ceeb Toom Kauj Ruam 13
Sau Daim Npav Ceeb Toom Kauj Ruam 13

Kauj Ruam 2. Sau ib qho kev kho lossis txheej txheem kev kho mob uas tus neeg mob yuav tsum tau sim

Yog koj xav tias tus neeg mob xav tau kev kho kom rov zoo, xws li los ntawm kev kho lub hlwb lossis lub cev, tsis txhob hnov qab suav nrog cov ntaub ntawv no. Ntawm qhov tod tes, yog tias tus neeg mob tsuas xav tau cov tshuaj uas kws kho mob hais, tsuas yog hais qhia hom tshuaj uas xav tau nrog rau qhov ntau npaum li cas thiab sijhawm kho.

Qee zaum, kev phais yuav tsum tau ua yog tias tus neeg mob mob txaus

Sau Sau Npe Ceeb Toom Kauj Ruam 14
Sau Sau Npe Ceeb Toom Kauj Ruam 14

Kauj Ruam 3. Suav nrog xa mus rau kev sab laj nrog kws tshaj lij, yog tias tsim nyog

Yog tias hom kev kho mob lossis kev kho mob xav tau los ntawm tus neeg mob tsis ua raws koj li kev paub, thov suav nrog kev xa mus rau kws kho mob tshwj xeeb uas tus neeg mob xav tau mus ntsib. Tshwj xeeb, qhia lub npe ntawm tus kws tshaj lij uas tsim nyog rau txhua qhov kev kuaj mob, yog tias qhov laj thawj tshwj xeeb tsis tau txheeb xyuas, yog li tus neeg mob paub yuav mus qhov twg ntxiv.

Ntu 5 ntawm 5: Teem SOAP Cov Ntawv Sau

Sau Daim Npav Ceeb Toom Kauj Ruam 15
Sau Daim Npav Ceeb Toom Kauj Ruam 15

Kauj Ruam 1. Sau tus neeg mob lub hnub nyoog, poj niam txiv neej, thiab kev tsis txaus siab thaum pib sau ntawv

Nyob rau sab saum toj ntawm SOAP cov ntaub ntawv, sau tus neeg mob lub hnub nyoog thiab poj niam txiv neej, tom qab ntawv tsis txaus siab kho mob. Txoj kev no, lwm tus kws kho mob tsuas yog xav saib koj cov ntaub ntawv ib zaug txhawm rau txheeb xyuas tus neeg mob qhov kev kuaj mob thiab kho tau.

Piv txwv li, koj tuaj yeem sau, "poj niam hnub nyoog 45 xyoos muaj mob plab," kom qhib SOAP ntawv

Sau Soap Note Step 16
Sau Soap Note Step 16

Kauj Ruam 2. Ua kom ntseeg tau qhov kev txiav txim ntawm cov ntsiab lus hauv SOAP cov ntaub ntawv raug

Qhov no txhais tau tias txhua tus neeg mob cov ntaub ntawv koj tau txais yuav tsum raug sau tseg hauv Hom Phiaj Xwm-Lub Hom Phiaj-Kev Ntsuam Xyuas-Kev Npaj. Yog li, lwm tus neeg kho mob uas nyeem daim ntawv yuav tsis plam lawv txoj kev. Yog tias koj xav tau, tsis txhob siv cov ntawv sau ua kab lus, koj tseem tuaj yeem siv cov ntsiab lus mos txwv. Xijpeem koj siv hom ntawv twg, xyuas kom cov txiaj ntsig tau meej, meej, thiab nyeem tau yooj yim.

Yeej, tsis muaj txoj cai hais txog hom ntawv lossis qhov ntev ntawm cov ntsiab lus, tsuav yog qhov kev txiav txim ntawm cov ntsiab lus hauv SOAP cov ntaub ntawv yog Tus Cwj Pwm-Lub Hom Phiaj-Kev Ntsuas-Kev Npaj

Tswv yim:

Ua kom ntseeg tau tias txhua qhov kev kho mob luv lossis cov lus yooj yim uas koj siv yog nkag siab yooj yim rau cov nyeem los ntawm txhua txoj kev ntawm lub neej.

Sau Daim Npav Ceeb Toom Kauj Ruam 17
Sau Daim Npav Ceeb Toom Kauj Ruam 17

Kauj Ruam 3. Sau lossis ntaus SOAP sau ntawv hauv hom ntawv uas koj qhov chaw ua haujlwm xav tau

Cov tsev kho mob feem ntau tau siv cov ntaub ntawv khaws cia digital siv cov ntawv online kom yooj yim dua cov txheej txheem ntawm kev sau thiab tshaj tawm SOAP cov ntaub ntawv. Txawm li cas los xij, tseem muaj qee qhov chaw uas xav kom cov neeg ua haujlwm tsim cov ntaub ntawv SOAP. Nco ntsoov tias koj ib txwm ua raws li hom ntawv xav tau los ntawm koj qhov chaw ua haujlwm txhawm rau ua kom yooj yim rau kev tswj hwm.

Lub tswv yim

Qhov tseeb, tsis muaj qhov txwv ntev lossis luv hauv kev sau SOAP cov ntawv. Qhov tseem ceeb tshaj plaws, daim ntawv yuav tsum muaj tag nrho cov ntaub ntawv tsim nyog thiab nyeem tau yooj yim

Ceeb toom

  • Npaj txhua ntu hauv SOAP cov ntaub ntawv kom nws zoo thiab nyeem tau yooj yim. Txoj kev ntawd, lwm tus neeg yuav tsis nkag siab thaum nyeem tus neeg mob cov ntaub ntawv kho mob uas koj tsim.
  • Yog li kom lwm tus tsis txhob poob siab thaum nyeem koj cov ntawv SOAP, tsis txhob siv ntau cov ntawv luv lossis cov ntawv luv hauv lawv.

Pom zoo: