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Exam 2 Study Guide

Exam 2 Study Guide - 443 Study Guide Exam 2 SOAP Note S...

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443 Study Guide- Exam 2 SOAP Note S: Subjective Data (paragraph) A pt or significant other’s expression of the f acts as PERCEIVED by them Exact words are usually quoted Include only information needed to support your assessment May be skipped if no pertinent information Medical history appears here only if the pt told you O: Objective Data (bullet) Lab results (Chol, LDL, HDL, TG, BP) Anthropometrics (ht, wt, BMI, waist, IBW, %IBW, %UBW) Medications (with nutritional implications) Physical exam (observations) Medical history (surgeries) Estimated calorie needs Info that can’t be argued with because its factual/reproducible A: Assessment (paragraph) Evaluation of the subjective and objective information previously recorded- nutritional Hx Must stay within the scope of nutrition services Apply clinical judgement Assess if pt is meeting needs and how you will attempt to meet needs 4 points to make in assessment Assess their wt Assess level of risk Evaluate diet recall Explaining your plan PES statement appears at the end of the assessment Plan: Plan (bullet) Written in past tense Course of action to resolve problem Current diet or diet recommendations Supplements and snacks Diet education Any necessary monitoring of labs, tolerance to diet, wt, po intake Look at medications to make sure to consider side effects Followup Clear description of the nutrition problem and the status Time frame of next appointment Progress related to plan What should be changed to accommodate to pt status ADI Form A: Assessment (paragraph) Calories needs
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Same assessment an in SOAP Note D: PES Statement (paragraph) Problem…r/t…etiology….aeb….signs/symptoms I: Intervention (bullet) Plan of the SOAP Note PES Statement= Nutrition Diagnosis P: Problem 3 domains: Intake when possible choose problem from this list Clinical Behavioral E: Etiology What is causing the problem What is the evidence S: Signs and symptoms Tells why “p” is the problem Monitor(s) to see improvement or no improvement of symptoms/signs/problem Diet Instruction Documentation Type of instruction Who was instructed List of written materials given to pt Assessment of understanding the diet Motivation to comply Plans for followup Alternative arrangements or materials Description of diet principles emphasized Can be written in paragraph/bullet Positions of the ADA: Intergration of MDNT and pharmacotherapy For patients receiving concurrent MNT and pharmacotherapy, ADA recommends that care be provided by: a team approach with dietetic professionals and other members of the healthcare team What is the most cost effective way to treat many diseases and their symptoms MNT and lifestyle counseling When pharmoacotherapy is necessary for certain disease states because of the long duration or complexity should MNT be continued and why?
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