On Tue, Sep 13, 2005 at 11:58:00AM -0700, Jim Busser wrote:
> We could have
> - diabetes mellitus (control)
> S - Having trouble adhering to diet. Checking ~ 2x daily, staggered
> times, 9-13 mmol/L
> O - Last A1C 0.09% ( is it under O we would comment on test results,
> or under A?)
Usually, in my notes, it's like this: when I go back to a
patients lab and muse about how test came out previously I
put it into Soap:
episode: pneumonia
rfe: still unwell
S - slowly getting better, but still temps up,
CPR was initially 163
If I am then doing another test in that encounter I'd put it
into sOap:
O - CRP today 77, crepitations getting better, less wheezing
lung X-ray showing less shading in the wrong places
I might note it down in soAp, too:
A - CRP 77 still to high for my liking, not resolved
And perhaps re-mention CRP in soaP, again !
P - continue ABs, expected CRP to be in the twenties, well, liver
metabolism is increased due to antiepileptics anyways,
so review next week - expect below 10
:-))
Karsten
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