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cwehde
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What is the first thing to do when meeting a client?
open with a heart felt greeting.
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What does SOAP mean?
- Subjective
- Objective
- Assessment
- Plan
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What is the Subjective section in SOAP include?
- owners observations, opinions, chief complaint, past Hx,
- Things not set in stone
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What is the Objective section in SOAP include?
- repeatable, measurable facts: vitals, PE, labs, age, weight
- things that are set in stone
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What is the Assessment section in SOAP include?
- 1st vet diagnosis, rule out based on subjective and objective
- 1st vet tech: what can we do to help?
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What is the Plan section in SOAP include?
treatment, lab orders, referral, procedures, perscription
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5 steps to a great interiew
- 1) Listen to story
- 2) Sort out important data
- 3) Ask probbing Q's
- 4) Observe nonverbal
- 5) be empathetic, understand concerns
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What are some open ended questions?
- Examples:
- Are they eating/drinking ordinarily
- are they passing fluid/stool
- what do you feed them?
- describe a typical day?
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Six areas to explore: Chief complaint
why are they here, assessing situation
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Six areas to explore: Past History
- Disease
- Vacc, Allergies
- Trauma
- Sx, Rx
- How long are they with client.
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Six areas to explore: Husbandry
- Diet
- Exposure other animals
- Exposure to elements
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Six areas to explore: Exercise
- Amount
- Frequency
- Type of w/o
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Six areas to explore: Medication
- Current and past
- Reactions
- Doses
- Frequency
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Six areas to explore: Geographical Hx
- Travel
- where they came from (petshop/shelter/out of state)
- Pior ownership?
- other animals travel that they've come into contact with.
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What should yo do afterward exploration?
Repeat back!
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What are the six areas to explore when asking questions?
- Chief Complaint
- Past history
- Husbandry
- Geographical Hx
- Medication
- Exercise
( Chief Geo told his ex husband about his past medication)
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