FOLLOW UP – SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN
After treatment begins, you need to follow how your patient improves and offer information to continue care. You need to:
- enquire about how they feel
- inform them about results of examinations or tests
- explain changes in their medication or care
- instruct them on any changes they need to make
For patients in hospital (in-patients), this check is done daily with each shift change during the day, or more often for sicker patients.
For patients who are not in hospital (out-patients), checks are done during each visit with the healthcare provider at a clinic or at the patient’s home.
Information that the healthcare provider records during follow-up includes:
- Subjective – what the patient has been feeling or experiencing
- Objective – what the healthcare provider finds on examination
- Assessment – summary of the patient’s current condition
- Plan – what change in care, if any, the patient should receive
Hence, sometimes these notes are called SOAP notes.
Subjective assessment – asking the patient how they feel:
General questions for any patient:
- How do you feel today?
- How are you feeling today? (How’re you feeling today?)
- How have you been since last visit? (How’ve you been since last visit?)
- How’ve you been doing (since we last spoke)?
- How did you sleep last night? (How’d you sleep last night?)
- How is your appetite today?
- Is your breathing more comfortable?
- Is your arm OR leg OR stomach OR back more comfortable?
- Are your symptoms improving?
- How is your pain? (How’s your pain?)
- Does your …(hip)… still bother you?
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