SOAP NOTES

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  • Опубликовано: 4 окт 2024
  • Jessica Nishikawa discusses the structure and function of the SOAP Note for medical notes. Subscribe / jessicanishikawa
    Follow Twitter @JessNishi

Комментарии • 170

  • @caseyburt9569
    @caseyburt9569 4 года назад +101

    OLDCARTS
    O- Onset when did the issue arise
    L- location of the pain
    D- Duration how long has the pain been going on for
    C- Characteristics is it throbbing, radiating, piercing pain
    A- Aggrevates what makes the pain worse
    R- Relieves what takes away the pain or lightens the pain
    T- Treatments have you taken any medications for the pain or issue
    S- Scale of 0 to 10 0 being no pain 10 being the worst pain imaginable what number do you fall in

    • @stefainepatricio9559
      @stefainepatricio9559 2 года назад

      Is this during the S or the P ?

    • @Fluxxxx
      @Fluxxxx 2 года назад

      SOCRATES

    • @caseyburt9569
      @caseyburt9569 2 года назад +4

      @@stefainepatricio9559 It would be subjective, as it is the patient telling you. You wouldn't be able to determine any of these, thus meaning it wouldn't be objective. Subjective, as well as objective, allows you to come up with a plan.

    • @yourkdrama-blfan1706
      @yourkdrama-blfan1706 Год назад

      This helps a lot on the HPI. Big thanks.

  • @danitajaundoo5459
    @danitajaundoo5459 6 лет назад +47

    This is exactly what I was searching for, for two whole days. Thank you so much, very clear explanation.

    • @yolandarivas7544
      @yolandarivas7544 4 года назад +1

      Thank you for sharing a simple and valued way to remember soap!

    • @rico4379
      @rico4379 2 года назад

      Same🙏

  • @MoLeaveBrainstainzz
    @MoLeaveBrainstainzz Год назад +9

    This video was posted 4 years ago, here I am today, 4 years later Thanking you tremendously for, doing the Lords work🙌🏽🙌🏽 😂😂(No seriously) I’ve been reading, researching, & pondering my blood pressure for an entire week trying to find an explanation of documentation In layman’s terms of S.O.A.P notes!! Thank you! thank you thank you!

  • @adimaca2359
    @adimaca2359 4 года назад +11

    Thank you so much for for this I’ve been searching for this for a very longtime and you’ve got the best version of it 👏 Now I know how to write soap notes.

  • @Cass_i
    @Cass_i 4 года назад +3

    Thank you. This really sums it all up plus the example made it a lot more concrete for me. This was the best.

  • @NLKEquestrian
    @NLKEquestrian 3 года назад +8

    Extremely helpful, thank you! I really needed to see how to write one of these quickly for my next OSCE!

    • @JessicaNishikawa
      @JessicaNishikawa  3 года назад +1

      Thanks for watching, good luck with your OSCE!

  • @celizabeth1220
    @celizabeth1220 Год назад +1

    THANK YOU!!! My textbook doesn't explain the SOAP method very well and this saved me for my exams in two days!

    • @JessicaNishikawa
      @JessicaNishikawa  Год назад

      Glad you found it helpful and I hope your exam went well!

  • @hajimusawer9637
    @hajimusawer9637 6 лет назад +3

    omg You are the best. I love the video and how simple you make everything look and sound. I am currently at Fort Sam and have to go through this in order to be a Navy Corpsman and this part is the only thing that sounded confusing UNTIL now lol
    thanks

  • @jenniferhinson5628
    @jenniferhinson5628 3 года назад +5

    At the end of this video you mention going into more detail for the NP students. Can you post the link for that video? I love your lectures! So easy to follow yet thorough!

  • @BritAlaina89
    @BritAlaina89 11 месяцев назад

    Thank you Jessica!!! This was right on time and very thorough!!

  • @malugarib1221
    @malugarib1221 8 месяцев назад

    Thank you, Jessica. Very useful and easy to understand.

  • @irvinmanzanares7275
    @irvinmanzanares7275 7 лет назад +11

    I liked this video because is very interesting and now I know to make a SOAP note.

  • @lamisingh7601
    @lamisingh7601 4 года назад

    Hey Jessica, this is Lami here.. I wanna tell u that I am very much impressed by your videos.. please keep updating this channel with more n more videos. These are really helpful, am looking forward for more informative uploads from you.
    THANKYOU n keep up the great work !
    Regards! :)

  • @martinamulbah8013
    @martinamulbah8013 4 года назад +1

    Your soap notes is the best 🙂

  • @boscoechon7036
    @boscoechon7036 6 лет назад +4

    Thanks a million yo work really makes my day brighter

  • @boscomoons7742
    @boscomoons7742 2 года назад +1

    Honestly, the video precisely informative. Thanks a million!

  • @learnpharmacywiththepharma7094
    @learnpharmacywiththepharma7094 2 года назад +1

    I can't thank you enough for this video like i was literally searching for a video that includes how to exactly write a case based soap note and i finally found this video.
    Thank you so much❤️

    • @JessicaNishikawa
      @JessicaNishikawa  Год назад

      SOAP notes aren't as hard as they are made out to be. Hope this simplified it a bit.

  • @kristiheiser5012
    @kristiheiser5012 8 лет назад +6

    Great explanation of SOAP, thanks!

  • @simonebuhner74
    @simonebuhner74 5 лет назад +2

    Clear, concise and very helpful, thank you!

  • @dhritimansen3307
    @dhritimansen3307 5 лет назад

    love love love the handwriting AND information obvs

  • @xxsnow_angelxx3953
    @xxsnow_angelxx3953 4 года назад +1

    so easily!! i love the art

  • @vannsylten6765
    @vannsylten6765 4 года назад +2

    This was incredibly helpful! Thanks for being straight and to the point!

  • @kristasmith4157
    @kristasmith4157 Год назад

    I don't know if you ever read these reviews anymore, but I met you in 2009 right after you had your daughter. I am currently in school for nursing and I saw your name and I thought...WOW, what are the odds! Hope this note finds you well :)
    This was a super helpful video btw

  • @rubenyero1508
    @rubenyero1508 2 года назад +2

    I’m currently in EMT school and we need to write two soap reports per ride time and this video was a really helpful breakdown 👍

  • @rpsingh18
    @rpsingh18 6 месяцев назад

    Very Helpful! Thank you for creating this!

  • @preparedmindstrongspirit5724
    @preparedmindstrongspirit5724 7 лет назад +4

    Thanks for the video! It is really helping me to get my head back in the med game after a long absence.

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад

      Thanks for watching, and I'm glad you're back in the game! :)

  • @hoangdoan642
    @hoangdoan642 2 года назад +2

    Very useful! Thank you so much 😍

  • @esel7162
    @esel7162 4 года назад

    Jessica you the greatest for this

  • @Nuf1av0r
    @Nuf1av0r 3 года назад

    Thank you! This helped me pass my NHA exam :)

  • @SFL3G
    @SFL3G 6 лет назад +2

    Thank you for all the great content

  • @sehrishrafeeque5919
    @sehrishrafeeque5919 4 года назад +1

    It's really worth watching it... Thank U soo much for sharing it in such an amazing way.. It helped me :)

  • @mobosh9454
    @mobosh9454 3 месяца назад

    It's very very good. Thank you for your awesome video. 👌👌👌👌🔥🔥🔥🔥

  • @robertkaranja3113
    @robertkaranja3113 4 года назад

    Jessica Nishikawa you are awesome

  • @elasion4384
    @elasion4384 4 года назад +1

    Thank you, this was very helpful.

  • @crisjeturian56
    @crisjeturian56 Год назад

    I love it, very informative! I love it and you..

  • @martinamulbah8013
    @martinamulbah8013 4 года назад +2

    This is what I was looking for too

    • @greenlove4572
      @greenlove4572 4 года назад

      Can you help me with my sports med hw. Lol 😂

  • @wengthoughts
    @wengthoughts 2 года назад +1

    thank u. I'll be having an exam soon regarding this.

  • @beatricekasamba
    @beatricekasamba 4 месяца назад

    Thanks dear it was helpful I really needed this

  • @NarrowRoad7
    @NarrowRoad7 2 года назад

    Thank you for sharing this with us. I got the full understanding:)

  • @camiblutube7116
    @camiblutube7116 4 года назад +1

    Love this! Could you please do a PES Statement? Thank you!

  • @pournimashrikhande4137
    @pournimashrikhande4137 2 года назад +1

    Very well explained

  • @mrs.mckeller1483
    @mrs.mckeller1483 5 лет назад

    Thank you soooooo much you have made it so east for me to understand!!

  • @MrsCoach1999
    @MrsCoach1999 2 года назад +1

    Love your videos! May I share with my students?

  • @kristencrane2872
    @kristencrane2872 6 лет назад +3

    I am guessing that an RN SOAP note would be different as far as the assessment part goes since nurses don't diagnose. In this case would a nursing diagnoses be part of the assessment?

    • @valeriewinnie
      @valeriewinnie 5 лет назад +3

      You are correct! as an RN you would use nursing diagnosis. In the case of the sore throat, for example, you could use "impaired comfort r/t sore throat" or "impaired oral mucous membrane r/t inflammation or infection of oral cavity", etc.

    • @claytongrey988
      @claytongrey988 4 года назад +1

      @@valeriewinnie thanks for that! I was about to ask the same question.

  • @elizabethpierce3647
    @elizabethpierce3647 7 лет назад +2

    Hi Jess! I love your videos! Thank you for putting the time and effort into them. Question:is this the video for the FNP students? You had mentioned that a more detailed/expansive video would be coming that was meant for FNP students. Is this the one?
    Thanks much!

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад

      Hi Elizabeth... I think I had intentions to do another video, but never got around to it. My 'to do' list got away from me for the last several years :) Thanks for watching. If you subscribe then you'll be notified when more videos are published. Aloha- J

    • @libbypierce3941
      @libbypierce3941 7 лет назад +1

      Jessica Nishikawa ,
      I'm wondering your opinion on an educational phenomena. There are a plethora of online FNP programs now, turning out literally thousands of new FNPs. How do you recommend FNP students develop that mastery of physical exam skills, when in an online program (in which all content is in a distance learning environment, except for clinical hours w/preceptor). How can the online student develop PE proficiency, BEFORE their clinical time under a preceptor? Ideas? Want to start a "Hawaii Boot Camp" for FNP students?!?! 😉

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад +1

      Hi Libby, if you are in a FULLY online program it can be challenging! You can try virtual patient experiences (iHuman or others), they will help develop clinical reasoning but not much actual physical examination techniques. You should also examine as many of your friends and family members as you can - until they're sick of you :) It will help a lot. Is there an NP school near you? You could try to get in on their study sessions. Wish you the best!

  • @Gymnopediea
    @Gymnopediea 5 лет назад +1

    I'm not sure if this is such a big deal but I've been taught to never write "denies HA, Rhinitis, etc" and instead to write "reports absence of HA, Rhinitis, etc"

  • @AaronmBenton1
    @AaronmBenton1 4 года назад

    Great info. Very simple

  • @natinuella5836
    @natinuella5836 3 года назад

    Wow just what needed
    Thank you

  • @markrobiso
    @markrobiso 2 года назад

    Another example using the Practice Fusion platform, please. Thank you!

  • @diyamajumder2711
    @diyamajumder2711 3 года назад

    Thank you very much this video very helpful for me

  • @big4020
    @big4020 7 лет назад

    Awesome clarification. Thank you

  • @rebeccadavies1687
    @rebeccadavies1687 4 года назад +1

    Hello :) Just a quick question. What does it mean when it says 'billed for'? Thank you

    • @JessicaNishikawa
      @JessicaNishikawa  4 года назад +1

      Hi Rebecca,
      Sorry I am getting to this message late. "Billed for" refers to the medical diagnoses that get submitted to insurance companies to support the billing for a patient encounter. As a medical provider in the United States you have to code your visits and then submit support for that code. Thanks for watching.

  • @chibuikemnnamdi6143
    @chibuikemnnamdi6143 Год назад

    Nice. I just need questions to practice with

  • @pradeeppati7932
    @pradeeppati7932 7 лет назад +2

    thank you mam. it is clear and simple to understand.nice video.

  • @julieadrian1422
    @julieadrian1422 3 года назад

    I see ROS is listed under subjective, should the ROS be under objective heading as this is an examination?

  • @farahwakil9479
    @farahwakil9479 8 лет назад +1

    Very nice thanks dr

  • @sharongonzales2495
    @sharongonzales2495 2 года назад

    SOOO HELPFUL 🥰

  • @audzlongaza9397
    @audzlongaza9397 5 лет назад

    Thank you for this. I learned a lot.

  • @nyenye5292
    @nyenye5292 3 года назад

    Perfect 🤩 thanks a bunch

  • @nidarajpot8250
    @nidarajpot8250 3 года назад

    Kindly make vedio on CORE pharmacotherapy plan and PRIME AND FARM note

  • @benjaminmanzano9284
    @benjaminmanzano9284 6 лет назад

    thank you for sharing with us

  • @harelljuanico4293
    @harelljuanico4293 7 лет назад +2

    Thanks for the video! Very helpful! May I ask a question? Do doctors always take the patient's review of systems, family history, social history etc. every consultation? Wouldn't it be redundant? Or do they keep a record of it? Awesome video!

    • @jessnishikawanursing570
      @jessnishikawanursing570 7 лет назад +1

      Hi Harell Juanico, thanks for watching! To some degree clinicians ask these questions on most patient encounters. Usually we keep it focused and only ask the part of those questions that is related to the reason they are being seen for that visit. The comprehensive past medical, family, social history and the comprehensive ROS can be updated annually or as needed, and then referenced. Good question!

    • @harelljuanico4293
      @harelljuanico4293 7 лет назад

      Okay thanks for clarification! More power to you!

  • @sultanshorbaji1988
    @sultanshorbaji1988 7 лет назад

    Thank u very much
    The video is really helpful

  • @joypauline3236
    @joypauline3236 2 года назад

    I was really having a hard time getting my Soap note last week😓😓 but I’m all good and that’s #Cybercredible# work 👍

  • @eightysixoneeightysix3184
    @eightysixoneeightysix3184 4 года назад

    very useful. thankieeee --- bsoa student

  • @asma16cool
    @asma16cool 2 года назад

    Thank you!

  • @jomo2952
    @jomo2952 7 лет назад +2

    that is helpful thank you .

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад

      Hi Jo, you are welcome. Thanks for watching and glad you found it helpful!

  • @ghousiahealthcarekarachi4541
    @ghousiahealthcarekarachi4541 3 года назад

    Good knowledge 👍😉

  • @KITAANDROO
    @KITAANDROO 4 года назад +3

    The words "Chief" is spelled wrong

    • @marietteslabbert4642
      @marietteslabbert4642 4 года назад

      and LIKLY

    • @AlexiHolford
      @AlexiHolford 4 года назад

      and she says he has 4/5 symptoms, but wrote 4/4

    • @AlexiHolford
      @AlexiHolford 4 года назад +1

      Allison, there's a typo in your comment as well. You wrote "words" instead of "word."

  • @delia5158
    @delia5158 7 лет назад +2

    Great video. Weird question- What software do you use for these videos?

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад +2

      Hi Dede, Sorry this is late reply. This particular video is made with an endless whiteboard program called VideoScribe. It's great and very user friendly! Thanks for watching! :)

  • @martinamulbah8013
    @martinamulbah8013 4 года назад

    Thanks for sharing

  • @MrPedrojose1967
    @MrPedrojose1967 5 лет назад

    Very interesting to use as a Telephone Triage Nurse.

  • @ShireenFatimaANBZ
    @ShireenFatimaANBZ Год назад +1

    helpful 👍

  • @TarekYahia-v2j
    @TarekYahia-v2j 3 месяца назад

    Thank u ❤

  • @melvayaredaguilar
    @melvayaredaguilar Год назад

    what is soap anyways?

  • @viohleta
    @viohleta 7 лет назад

    Very helpful

  • @kanantalukder557
    @kanantalukder557 2 года назад

    Thanks❤️❤️

  • @malloryminer2796
    @malloryminer2796 9 лет назад

    the link did not work because I do not have a UH login

  • @homeguys6133
    @homeguys6133 6 лет назад +1

    You increased the lisinopril without a plan to recheck his U+E and renal function :/

    • @JessicaNishikawa
      @JessicaNishikawa  6 лет назад +2

      Hi HOME Guys, thanks for watching and taking the time to comment. If you were watching a little more carefully you would notice that the lisinopril wasn't actually increased. It was Lisinopril 20mg and at the end was still lisinopril 20mg (insert shrug emogi). Which was actually an oversight :) But one I didn't think required correction since the video is not about HTN management but about how to write a SOAP note (see clever title and video intro). If you're looking for videos about hypertension management I could recommend resources, just let me know.
      Aloha!

  • @fani4704
    @fani4704 6 лет назад

    Why would family history not be included?

    • @JessicaNishikawa
      @JessicaNishikawa  6 лет назад +1

      It would :) Did I not mention it?
      I tend to leave it out of day to day practice because most of the people i work with are older adults and I find it a bit ironic to ask a 90 year old if their parents had any cancers or major medical history. :)

  • @melvayaredaguilar
    @melvayaredaguilar Год назад

    I thought this was a video about cleanliness soap

  • @Ann-pn9or
    @Ann-pn9or 2 месяца назад

    you also misspelled emesis

  • @babbulvideos
    @babbulvideos 6 лет назад

    what program did you use to make this video?

  • @christinacidoni803
    @christinacidoni803 5 лет назад

    does it make a difference when you spell words wrong? Chief

  • @reesejackson1984
    @reesejackson1984 3 года назад

    Define and List subjective data in pain assessment. Chief complaint history of present illness past medical history social history
    2. Define and List objective data in pain assessment.
    Record physical findings vital signs general survey gent lymph
    3. List 10 possible causes of discomfort.
    4. List several methods for pain control.

  • @glowilk5377
    @glowilk5377 3 года назад

    Spelling counts in documentation 👍

  • @AntoinetteChanel
    @AntoinetteChanel 7 лет назад +1

    Hi there - I work in curriculum design and would like to use this video as part of the background information for an assignment I am putting together. I didn't see any contact info for you, but may I have your permission to use this video? I can explain further via email.

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад

      Aloha - you can email me at Jnishikawa@hpu.edu . But generally speaking - you are free to use any ot

    • @JessicaNishikawa
      @JessicaNishikawa  7 лет назад

      Sorry about that--- You are free to use any of the videos.

  • @SongsbyMaggieMay
    @SongsbyMaggieMay День назад

    Subjective: chief, complaint,
    History of present illness, past medical history, family history, social history, review of systems,
    objective: vital signs, general survey, genes, lymph, chest, CV, abdominal ect
    Assent: global assessment of patient including differential diagnosis. In order from most likely to least likely
    Plan: diagnostic tests that will be ordered drugs of treatments that will be prescribed
    Patient education follow up

  • @its_taliaaa_9142
    @its_taliaaa_9142 4 года назад

    So you wouldn't order a throat culture?

  • @eightysixoneeightysix3184
    @eightysixoneeightysix3184 4 года назад

    don't mind me.. im just here cos prof told me to watch.

  • @Alex-bd4ov
    @Alex-bd4ov 4 года назад

    Great.

  • @samalimax1433
    @samalimax1433 7 лет назад

    Very well

  • @ericberger4511
    @ericberger4511 4 года назад +2

    "Chief" is misspelled. Like my parents always warned me - it distracts from the rest of your infoirmation.

    • @JessicaNishikawa
      @JessicaNishikawa  3 года назад +2

      You are hired as voluntary video editor :)

    • @ericberger4511
      @ericberger4511 3 года назад

      @@JessicaNishikawa Sorry. I'm doing my nremt refresh right now so I'm sensitive to typos

  • @maimai2344
    @maimai2344 3 года назад

    I thought this was the soap you use

  • @nafisemahmoodpoor8494
    @nafisemahmoodpoor8494 3 года назад

    Great

  • @Ann-pn9or
    @Ann-pn9or 2 месяца назад

    you misspelled CHIEF...lol, sorry I had to...

  • @zenitsu3760
    @zenitsu3760 2 года назад

    Spelled likely wrong @2:29

  • @joshuawick5382
    @joshuawick5382 4 года назад

    This is difficult.

  • @batoolhayat3393
    @batoolhayat3393 3 года назад

    it's not Emisis its emesis spelling correction. Thank you

  • @alainaharmon2575
    @alainaharmon2575 2 года назад

    From Cyber Credible