Jessica Nishikawa discusses the structure and function of the SOAP Note for medical notes. Subscribe / jessicanishikawa Follow Twitter @JessNishi
Пікірлер: 170
@caseyburt95694 жыл бұрын
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
@stefainepatricio95592 жыл бұрын
Is this during the S or the P ?
@Fluxxxx2 жыл бұрын
SOCRATES
@caseyburt95692 жыл бұрын
@@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 Жыл бұрын
This helps a lot on the HPI. Big thanks.
@danitajaundoo54596 жыл бұрын
This is exactly what I was searching for, for two whole days. Thank you so much, very clear explanation.
@yolandarivas75444 жыл бұрын
Thank you for sharing a simple and valued way to remember soap!
@rico43792 жыл бұрын
Same🙏
@MoLeaveBrainstainzz Жыл бұрын
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!
@JessicaNishikawa Жыл бұрын
You are welcome :) I'm glad you find it helpful!
@adimaca23594 жыл бұрын
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.
@NLKEquestrian3 жыл бұрын
Extremely helpful, thank you! I really needed to see how to write one of these quickly for my next OSCE!
@JessicaNishikawa3 жыл бұрын
Thanks for watching, good luck with your OSCE!
@Cass_i4 жыл бұрын
Thank you. This really sums it all up plus the example made it a lot more concrete for me. This was the best.
@celizabeth1220 Жыл бұрын
THANK YOU!!! My textbook doesn't explain the SOAP method very well and this saved me for my exams in two days!
@JessicaNishikawa Жыл бұрын
Glad you found it helpful and I hope your exam went well!
@jenniferhinson56283 жыл бұрын
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!
@fernanar17 жыл бұрын
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 again
@pfcaraujo4 жыл бұрын
Amy thanks for what you do Doc!
@BritAlaina8911 ай бұрын
Thank you Jessica!!! This was right on time and very thorough!!
@malugarib12217 ай бұрын
Thank you, Jessica. Very useful and easy to understand.
@irvinmanzanares72757 жыл бұрын
I liked this video because is very interesting and now I know to make a SOAP note.
@boscomoons7742 Жыл бұрын
Honestly, the video precisely informative. Thanks a million!
@JessicaNishikawa Жыл бұрын
Glad it was helpful!
@boscoechon70366 жыл бұрын
Thanks a million yo work really makes my day brighter
@martinamulbah80134 жыл бұрын
Your soap notes is the best 🙂
@lamisingh76013 жыл бұрын
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! :)
@dhritimansen33075 жыл бұрын
love love love the handwriting AND information obvs
@kristiheiser50128 жыл бұрын
Great explanation of SOAP, thanks!
@JessicaNishikawa8 жыл бұрын
+Kristi Heiser Thanks for watching!
@kristasmith4157 Жыл бұрын
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
@simonebuhner745 жыл бұрын
Clear, concise and very helpful, thank you!
@mobosh94543 ай бұрын
It's very very good. Thank you for your awesome video. 👌👌👌👌🔥🔥🔥🔥
@rpsingh186 ай бұрын
Very Helpful! Thank you for creating this!
@xxsnow_angelxx39534 жыл бұрын
so easily!! i love the art
@learnpharmacywiththepharma70942 жыл бұрын
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 Жыл бұрын
SOAP notes aren't as hard as they are made out to be. Hope this simplified it a bit.
@rubenyero15082 жыл бұрын
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 👍
@JessicaNishikawa Жыл бұрын
Glad it was helpful!
@esel71624 жыл бұрын
Jessica you the greatest for this
@hoangdoan6422 жыл бұрын
Very useful! Thank you so much 😍
@Nuf1av0r3 жыл бұрын
Thank you! This helped me pass my NHA exam :)
@SFL3G6 жыл бұрын
Thank you for all the great content
@sehrishrafeeque59194 жыл бұрын
It's really worth watching it... Thank U soo much for sharing it in such an amazing way.. It helped me :)
@beatricekasamba4 ай бұрын
Thanks dear it was helpful I really needed this
@vannsylten67654 жыл бұрын
This was incredibly helpful! Thanks for being straight and to the point!
@preparedmindstrongspirit57247 жыл бұрын
Thanks for the video! It is really helping me to get my head back in the med game after a long absence.
@JessicaNishikawa7 жыл бұрын
Thanks for watching, and I'm glad you're back in the game! :)
@robertkaranja31134 жыл бұрын
Jessica Nishikawa you are awesome
@elasion43844 жыл бұрын
Thank you, this was very helpful.
@wengthoughts2 жыл бұрын
thank u. I'll be having an exam soon regarding this.
@kristencrane28726 жыл бұрын
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?
@valeriewinnie5 жыл бұрын
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.
@claytongrey9884 жыл бұрын
@@valeriewinnie thanks for that! I was about to ask the same question.
@Gymnopediea5 жыл бұрын
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"
@martinamulbah80134 жыл бұрын
This is what I was looking for too
@greenlove45724 жыл бұрын
Can you help me with my sports med hw. Lol 😂
@pournimashrikhande41372 жыл бұрын
Very well explained
@JessicaNishikawa Жыл бұрын
Glad it was helpful!
@NarrowRoad72 жыл бұрын
Thank you for sharing this with us. I got the full understanding:)
@crisjeturian56 Жыл бұрын
I love it, very informative! I love it and you..
@mrs.mckeller14835 жыл бұрын
Thank you soooooo much you have made it so east for me to understand!!
@camiblutube71164 жыл бұрын
Love this! Could you please do a PES Statement? Thank you!
@MrsCoach19992 жыл бұрын
Love your videos! May I share with my students?
@JessicaNishikawa2 жыл бұрын
Of course :)
@big40207 жыл бұрын
Awesome clarification. Thank you
@elizabethpierce36477 жыл бұрын
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!
@JessicaNishikawa7 жыл бұрын
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
@libbypierce39417 жыл бұрын
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?!?! 😉
@JessicaNishikawa7 жыл бұрын
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!
@AaronmBenton14 жыл бұрын
Great info. Very simple
@natinuella58363 жыл бұрын
Wow just what needed Thank you
@ShireenFatimaANBZ Жыл бұрын
helpful 👍
@audzlongaza93975 жыл бұрын
Thank you for this. I learned a lot.
@diyamajumder27113 жыл бұрын
Thank you very much this video very helpful for me
@markrobiso2 жыл бұрын
Another example using the Practice Fusion platform, please. Thank you!
@harelljuanico42937 жыл бұрын
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!
@jessnishikawanursing5707 жыл бұрын
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!
@harelljuanico42937 жыл бұрын
Okay thanks for clarification! More power to you!
@chibuikemnnamdi6143 Жыл бұрын
Nice. I just need questions to practice with
@julieadrian14223 жыл бұрын
I see ROS is listed under subjective, should the ROS be under objective heading as this is an examination?
@TarekYahia-v2j3 ай бұрын
Thank u ❤
@pradeeppati79327 жыл бұрын
thank you mam. it is clear and simple to understand.nice video.
@farahwakil94798 жыл бұрын
Very nice thanks dr
@asma16cool2 жыл бұрын
Thank you!
@benjaminmanzano92846 жыл бұрын
thank you for sharing with us
@sharongonzales24952 жыл бұрын
SOOO HELPFUL 🥰
@nyenye52923 жыл бұрын
Perfect 🤩 thanks a bunch
@rebeccadavies16874 жыл бұрын
Hello :) Just a quick question. What does it mean when it says 'billed for'? Thank you
@JessicaNishikawa4 жыл бұрын
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.
@joypauline32362 жыл бұрын
I was really having a hard time getting my Soap note last week😓😓 but I’m all good and that’s #Cybercredible# work 👍
@sultanshorbaji19887 жыл бұрын
Thank u very much The video is really helpful
@nidarajpot82503 жыл бұрын
Kindly make vedio on CORE pharmacotherapy plan and PRIME AND FARM note
@eightysixoneeightysix31844 жыл бұрын
very useful. thankieeee --- bsoa student
@MrPedrojose19675 жыл бұрын
Very interesting to use as a Telephone Triage Nurse.
@martinamulbah80134 жыл бұрын
Thanks for sharing
@kanantalukder5572 жыл бұрын
Thanks❤️❤️
@ghousiahealthcarekarachi45413 жыл бұрын
Good knowledge 👍😉
@delia51587 жыл бұрын
Great video. Weird question- What software do you use for these videos?
@JessicaNishikawa7 жыл бұрын
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! :)
@reesejackson19843 жыл бұрын
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.
@viohleta7 жыл бұрын
Very helpful
@jomo29527 жыл бұрын
that is helpful thank you .
@JessicaNishikawa7 жыл бұрын
Hi Jo, you are welcome. Thanks for watching and glad you found it helpful!
@glowilk53772 жыл бұрын
Spelling counts in documentation 👍
@Alex-bd4ov4 жыл бұрын
Great.
@nafisemahmoodpoor84943 жыл бұрын
Great
@samalimax14337 жыл бұрын
Very well
@malloryminer27968 жыл бұрын
the link did not work because I do not have a UH login
@melvayaredaguilar Жыл бұрын
what is soap anyways?
@KITAANDROO4 жыл бұрын
The words "Chief" is spelled wrong
@marietteslabbert46424 жыл бұрын
and LIKLY
@AlexiHolford4 жыл бұрын
and she says he has 4/5 symptoms, but wrote 4/4
@AlexiHolford4 жыл бұрын
Allison, there's a typo in your comment as well. You wrote "words" instead of "word."
@babbulvideos6 жыл бұрын
what program did you use to make this video?
@JessicaNishikawa6 жыл бұрын
Videoscribe. It's awesome!
@melvayaredaguilar Жыл бұрын
I thought this was a video about cleanliness soap
@homeguys61336 жыл бұрын
You increased the lisinopril without a plan to recheck his U+E and renal function :/
@JessicaNishikawa6 жыл бұрын
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!
@eightysixoneeightysix31844 жыл бұрын
don't mind me.. im just here cos prof told me to watch.
@fani47046 жыл бұрын
Why would family history not be included?
@JessicaNishikawa6 жыл бұрын
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. :)
@Ann-pn9or2 ай бұрын
you also misspelled emesis
@christinacidoni8034 жыл бұрын
does it make a difference when you spell words wrong? Chief
@JessicaNishikawa4 жыл бұрын
knot reely ;)
@AntoinetteChanel7 жыл бұрын
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.
@JessicaNishikawa7 жыл бұрын
Aloha - you can email me at Jnishikawa@hpu.edu . But generally speaking - you are free to use any ot
@JessicaNishikawa7 жыл бұрын
Sorry about that--- You are free to use any of the videos.
@alainaharmon25752 жыл бұрын
From Cyber Credible
@schalkwillemfichardt57782 жыл бұрын
not the best but will work, thanks.
@JessicaNishikawa Жыл бұрын
Ha! Not very kind but thats ok, thanks for watching.
@Ann-pn9or2 ай бұрын
you misspelled CHIEF...lol, sorry I had to...
@splitaxis3 жыл бұрын
It's not subjective that he is a 62 year old male taking a bunch of meds and has specific allergies. Those are facts.
@JessicaNishikawa3 жыл бұрын
This is SOAP notes for beginners so there are simplifications. Follow these steps though and no one will ever question your SOAP note structure.. You can certainly put information in many other sections as well as you become more versed in medical documentation. But to address your specific statement/questions, those things are subjective if the patient is telling that information to you. Ie: new patients, new patients to your group, history taking, etc. If you are seeing the patient have an allergic reaction, you would put your examination findings in the objective information. It's easiest to think of everything as subjective except for what you are seeing/examining (objective). Thanks for watching! J
@splitaxis3 жыл бұрын
@@JessicaNishikawa Subjective is how the patient describes the symptoms of a disease / injury and their current physical /mental state according to their perception. Subjectivity does not extend into their name, age, sex, meds, PMH, PSH, allergies as those are facts. For example, subjectively they may say they are in pain but objectively there is no sign of trauma or any evidence of pain. You cannot say that subjectively they are a 62-year-old male but objectively this is a 25-year old female because you would just state a fact of their identity. You would explicitly state that "patient identifies as a 62-year-old male who is, in fact, a 25-year-old female" What you did was to mix in a 1 - 3 sentence patient introduction with subjective information. This is what makes the SOAP note confusing to others when people mix a bunch of stuff together and call it "subjective".
@JessicaNishikawa3 жыл бұрын
@@splitaxis Thank you for weighing in with your opinions. Within the confines of a SOAP note, in which section do you suggest students put that other information.
@splitaxis3 жыл бұрын
@@JessicaNishikawa John is a 62-year-old male with a PMH of diabetes who presents today with foot pain. SUBJECTIVELY he describes the pain as ba bla bla bla bla. OBJECTIVELY his vital are bla bla bbla and his physical exam is notable for bla bla. The style is really 1 -3 liner intro followed by SOAP. This is why so many notes include name age and sex in subjective parts in EPIC even though they don't belong there at all. It really should be ISOAP but that doesn't sound as good.
@JessicaNishikawa3 жыл бұрын
@@splitaxis Sure! That works. You'll find out in practice it actually doesn't matter where the information is as long as the billers can find it... but organization is helpful to easily identified information for future reference.
@priyosquad73843 жыл бұрын
Nice 386
@maimai23443 жыл бұрын
I thought this was the soap you use
@its_taliaaa_91424 жыл бұрын
So you wouldn't order a throat culture?
@zenitsu37602 жыл бұрын
Spelled likely wrong @2:29
@ericberger45113 жыл бұрын
"Chief" is misspelled. Like my parents always warned me - it distracts from the rest of your infoirmation.
@JessicaNishikawa3 жыл бұрын
You are hired as voluntary video editor :)
@ericberger45113 жыл бұрын
@@JessicaNishikawa Sorry. I'm doing my nremt refresh right now so I'm sensitive to typos