Introduction
Both SOAP and PIE charting techniques are used in the medical field to record patient data such as medical history, diagnosis, treatment, and symptoms. Healthcare professionals who must accurately communicate and document patient care can benefit from each method because it presents patient data uniquely. This essay will summarize SOAP and PIE charting, discuss their applications in healthcare careers, and propose improvements and better ways to convey this information.
SOAP Charting
Subjective, objective, assessment, and plan are referred to as SOAP. This method of charting meticulously documents the patient’s complete medical and social history, diagnoses, treatments, medications, outcomes, and any other pertinent information (Anantha Naik Nagappa & Naik, 2022). The patient’s complaints and account of their experiences make up the chart’s subjective section.
The objectives include physical findings or data, such as those from tests or laboratory examinations. The assessment component consists of the conclusion that a clinician draws after considering the patient’s symptoms and other data. The plan includes instructions from the clinician, including recommendations for new medications, follow-up instructions, and dietary advice.
Applications in Healthcare Careers
Employing SOAP charts will be invaluable in my chosen career as a healthcare professional. This charting method offers a systematic, all-inclusive way to keep track of vital patient information necessary for diagnosis and treatment planning (Glick et al., 2021). When managing many patients and making decisions quickly, the ability to read and interpret such data quickly and accurately is especially useful.
Proposed Improvements and Better Ways of Conveying Information
Even though the SOAP charting method efficiently records patient information, some areas can be improved to ensure better communication between medical professionals. For instance, vitals and findings should be recorded uniformly to simplify comparisons between various healthcare professionals and across various patient visits (Schloss & Konam, 2020). Additionally, the steps the clinician has taken to diagnose and treat the patient should be communicated in the assessment and plan section of the document.
Case Study
Subjective
81-year-old John Smith visited the clinic to see Dr. Jerry Jones. John reported feeling both subjective leg weakness and pain in his left arm. He claimed that climbing stairs makes his pain worse. He claims he is generally exhausted, and the pain is aching and worse in the evening.
Objective
After examination, it was discovered that John’s blood pressure was 165/85, and his pulse oximetry was 97%. His temperature was recorded at 98.5, and he breathed at 16 breaths per minute with a pulse rate of 60. His height was listed as 182 cm (5’11”), and his weight as 165 kg (363.8 lb). John’s ankles on both sides have peripheral edema. On physical examination, both lower legs had inflammation. No fractures were found after an X-ray was taken.
Assessment
Diabetes, heart disease, bilateral edema in the legs and ankles, and hypertension are John’s primary medical diagnoses. Further examination reveals that his strength has decreased due to ailments of the chest and abdominal walls and maturing age.
Plan
John needs to elevate his legs for an hour every four hours. This tactic should help relieve the pressure in his legs, which should lessen the pain and swelling. Mr. Smith may benefit from increasing his strength through low-impact exercise. John should also wear support stockings until his next appointment.
Dr. Jones advised taking one 25 mg Hydrochlorothiazide tablet daily in the morning for medical management. The choice is based on the antihypertensive drug’s approved indication to reduce swelling. Systolic and diastolic blood pressure levels must be monitored and treated accordingly. John needs to follow up at the clinic in two weeks.
Summary
John Smith, an 81-year-old man, was diagnosed with hypertension, bilateral edema of the legs and ankles, heart disease, and diabetes after presenting with various illnesses. John was told to do low-impact exercises and elevate his legs for four hours daily to help with his symptoms. He must follow Dr. Jones’ instructions and take one 25 mg tablet of hydrochlorothiazide daily in the morning. Up until his next appointment, John should also wear support stockings. Finally, he has a follow-up appointment in two weeks.
PIE Charting
PIE stands for problem, intervention, and evaluation in a charting method. It is employed to observe and record the treatment provided to a patient step by step. Following the identification of the issue, a list of suitable solutions is provided. After implementing the interventions, they are assessed to see if the objectives were achieved. This charting approach is employed in various healthcare specialties and enables efficient team communication (Murphy et al., 2020). Numerous professions can be applied using the PIE charting method.
Application in Healthcare Careers
As a health professional, I can use PIE Charting to improve patient care. This application can help diagnose and treat patients more effectively and efficiently (Murphy et al., 2020). In addition to helping me interpret patient data, PIE Charting also gives me an in-depth understanding of my patients’ progress over multiple visits, allowing me to determine intervention effectiveness. By doing this, I can evaluate each patient’s progress more effectively and create a care plan that will help the patient achieve better medical results.
Suggested Enhancements and More Effective Methods of Presenting Information
Some areas, like PIE Charting, can be enhanced to ensure clearer communication among healthcare providers. For example, to provide more complete records, the problem section should include additional information, such as lab results and vital signs (Kim et al., 2020). In addition, the interventions ought to be easy to understand, straightforward, and clear (Kim et al., 2020). Last, the evaluation section should include more in-depth remarks on how the patient responded to the interventions.
Case Study
The PIE Charting Assignment calls for a discussion of a case study in which a person has trouble identifying a problem and using the PIE Charting method to solve it. Mrs. Susan Gardner, a 68-year-old woman with a long history of chronic pain, is the patient in this case study. On numerous occasions, Mrs. Gardner has sought pain relief from her primary care physician, but it has proven elusive.
Problem
Mrs. Gardner has endured years of chronic pain, which has significantly disrupted her life and caused her great discomfort. She has undergone physical therapy, been given some prescription medications, and changed her lifestyle, but the pain persists and significantly impacts her quality of life. As a result, Mrs. Gardner finds it difficult to complete tasks that she used to complete easily, leaving her frustrated and depressed.
Unfortunately, the therapies she has tried thus far have not worked, so she needs to find new ways to deal with her persistent pain. Even though it is a challenging situation, Mrs. Gardner is steadfast and optimistic that she will eventually be able to end her suffering and return to a fulfilling lifestyle.
Interventions
Using the PIE Charting Method, an effective intervention strategy for Mrs. Gardner has been developed, considering all medical contraindications. Careful consideration of her specific needs is required for effective intervention design. Before anything else, an effort should be made to pinpoint and deal with the physical causes of her pain.
This could be accomplished by performing a thorough physical examination to find any physical sources of her pain, such as muscle imbalances, joint lubrication, or poor body alignment. An interdisciplinary approach that combines physical therapy with other modalities like massage, hydrotherapy, and yoga can help restore musculoskeletal balance by improving mobility and range of motion.
The second step is to carry out psychological interventions to deal with any emotional problems that might be causing her pain. Managing emotional problems like depression, anxiety, or stress, which can exacerbate pain symptoms, may benefit from talk therapy with a qualified psychologist or counselor. Further methods for lowering stress and enhancing coping abilities include breathing exercises, guided meditation, mindfulness, and relaxation techniques.
Evaluation
The PIE Charting Method’s evaluation phase requires a systematic assessment of whether the interventions effectively relieve Mrs. Gardner’s pain. This progress must be reviewed regularly to assess the effectiveness of the interventions, and Mrs. Gardner’s opinion of the treatments must be considered.
One sign of the intervention’s success is Mrs. Gardner’s ability to increase her activities and performance levels as the interventions manage the pain. This could imply that Mrs. Gardner can resume her normal activities or even go above and beyond to achieve higher activity levels. This must be monitored to ascertain whether the interventions have had the desired impact.
Summary
In conclusion, the PIE Charting Method is a thorough and efficient method for treating patients with chronic pain like Mrs. Gardner. Thanks to carefully evaluating her medical history and carefully crafted interventions tailored to her situation, Mrs. Gardner should have a better chance of experiencing pain relief. Mrs. Gardner must undergo continuous evaluation and intervention modification to get the most out of her treatments and live a fulfilling life.
References
Anantha Naik Nagappa, & Naik, V. (2022). Pharmaceutical Care: WHO-FIP Model, Soap Analysis, and Illustrative Case Studies. 73–86. Web.
Glick, M., Greenberg, M. S., Lockhart, P. B., & Challacombe, S. J. (2021). Introduction to oral medicine and oral diagnosis. Burket’s Oral Medicine, 1–18. Web.
Kim, S., Trinidad, B., Mikesell, L., & Aakhus, M. (2020). Improving prognosis communication for patients facing complex medical treatment: A user-centered design approach. International Journal of Medical Informatics, 141, 104147. Web.
Murphy, R., Calugi, S., Cooper, Z., & Dalle Grave, R. (2020). Challenges and opportunities for enhanced cognitive behavior therapy (CBT-E) in light of COVID-19. The Cognitive Behaviour Therapist, 13(14). Web.
Schloss, B., & Konam, S. (2020). Towards an Automated SOAP Note: Classifying Utterances from Medical Conversations. Proceedings. mlr.press; PMLR. Web.