Rule of Nines

"Rule of Nines"

It is a method of estimating the extent of burns, expressed as a percentage of total body surface. In this method, the body is divided into sections of 9 per cent, or multiples of 9 per cent, each: head and neck, 9 per cent; anterior trunk, 18 per cent; posterior trunk, 18 per cent; upper limbs, 18 per cent; lower limbs, 36 per cent; genitalia and perineum, 1 per cent. The rule of nines is fairly accurate for adults but does not allow for differences in proportion in children, for whom the lund and browder classification is generally used.

S.O.A.P

A Case Presentation is a formal communication between health care professionals (doctors,
pharmacists, nurses, therapists, nutritionist etc.) regarding a patients clinical information.
The SOAP note (an acronym for subjective, objective, assessment and plan) is a method of documentation employed by healthcare providers to write out notes in a patient chart.
Many hospitals use the SOAP note format to standardize medical evaluation entries made in clinical records. 
The SOAP note is written to improve communication among all those caring for the patient to display the assessment, problems and plan in an organized format. 
SOAP notes facilitate better medical care when used in the patients record for review and quality control.
The SOAP note is not supposed to be as detailed as a progress report. Complete sentences are not necessary and abbreviations are appropriate.
The SOAP note should briefly express the following:

• Date and purpose of the visit
• The patient’s symptoms and complaints
• The current physical exam: patient’s height, weight, temperature, pulse,  blood pressure,visual acuity, etc.
• New lab data and results of studies, reports, assessments.
• The current formulation and plan for the patient.

S-O-A-P
1. SUBJECTIVE – The initial portion of the SOAP note format consists of subjective observations. These are symptoms, the patient verbally expresses or as stated by a significant other. The subjective observations include the patient’s descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort or illness the patient describes.
2. OBJECTIVE – The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.
3. ASSESSMENT – assessment follows the objective observation. Assessment is the diagnosis of the patient condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibly.
4. PLAN – The last part of the SOAP note is the health care provider’s plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (eg. Minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (eg. Home care, bed rest, short term, long term disability, days excused from work, admission to hospital), patient directions (eg. Elevate foot, RTO 1 week), and follow up directions for the patient.
Examples for abbreviations used in SOAP notes:
WT = Weight
HT = Height
IBW = Ideal Body Weight
BP = Blood Pressure
Chol = Cholesterol
Pt = Patient
RTO = Return to office
ROM = Range Of Motion
R/O = Rule Out
PA = Posterior or Anterior
P – Pallor
I – Icterus
C – Cyanosis
C – Clubbing
L – Lymphedenopathy
E – Edema
NKDA = No Known Drug Allergies
NKA = No Known Allergies
P = Pulse
Temp/ T = Temperature
BS = Blood Sugar
UA = Urine Analysis
VA = Vision Acuity
O.S. = Left Eye
O.D. = Right Eye
O.U. = Both Eyes

Standard elements of SOAP notes

Date :
Time :
Provider :
Vital signs :
Height, Weight, Temperature, BP, Pulse
Subjective : This ____ yr old fe/male presents for ____________
History of present illness symptoms :
Review of symptoms/systems : (for problem – focused visit, document only pertinent
information)
Current medications :
Medication allergies :
Social history : (for problem – focused visit, document only pertinent information)
Family history : (for problem – focused visit, document only pertinent information)
Genogram : Three generations with health problems, causes of deaths, etc.
Or history of major health or genetic disorders in the family, including early death, spontaneous
abortions or stillbirths.
Objective : (listed are the components of the all normal physical exam)
General: Well appearing, well nourished , in no distress. Oriented x 3, normal mood and affect,
ambulating without difficulty.
Skin: Good turgor , no rash, unusual bruising or prominent lesions.
Hair: Normal texture and distribution.
Nails: Normal colour , no deformities.
HEENT:
Head: Normocephalic, traumatic, no visible or palpable masses, depressions or scarings.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or heamorrhage.
Ears: EACs clear, TMs translucent and mobile, ossicles appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal.
Mouth: Mucous membrane moist , no mucosal lesions.
Teeth or Gums: No obvious carries or periodontal disease. No gingival inflammation or significant reabsorption.
Pharynx: Mucosa non-inflammed, no tonsillar hypertrophy or exudates.
Neck: Supple, without lesions , bruits, or oedenopathy, thyroid non-enlarged and non- tender.
Heart: No cardiomegaly or thrills, regular rate and rhythm , no murmur or gallop.
Lungs: Clear to auscultation and percussion.
Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses or hernia.
Back: Spine normal without deformity or tenderness, no CVA tenderness.
Rectal: Normal sphincter tone , no hemorrhoids or masses palpable.
Extremities: No amputations or deformities , cyanosis, edema or vericosities, peripheral pulses intact.
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitations, defects,tenderness, masses, effusion, decreased range of motion, instability, atrophy, abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic : CN 2- 12 normal. Sensation to pain, touch and proprioception normal. DTRs normal in upper and lower extremities. No pathologic reflexes.
Psychiatric : Oriented x 3, intact recent and remote memory, judgement and insight, normal mood and affect.
Pelvic : Vagina in cervix without lesions or discharge. Uterus and admexa/parametria non tender
without masses.
Breast : No nipple abnormality, dominant masses, tenderness to palpations, axillary or supraclavicular adenopathy.
G/U : Penis circumcised without lesions, urethral meatus normal location without discharge,testes and epididmides normal size without masses, scrotum without lesions.
Assessment : Includes health status and need for lifestyle changes.
Diagnosis and differential diagnosis :
Plan laboratory :
X-Rays :
Medications :
Patient Education :
Other :
Follow-up :

Examples for SOAP notes

SOAP note Example 1 :
Patient name : Manikkam DOB : 12/12/1979
Record No. : 123456
Date : 10/10/2010
S – Patient states that she has always been overweight. She is very frustrated with trying to diet.
Her 20 year class reunion is next year and she would like to begin working towards a weight loss
goal that is realistic. NKDA, NKA.
O – WT=210 lbs HT = 60” BW=115lbs Chol=255 BP=120/75mmHg
A – Obese at 183% IBW, hypercholesterolemia
P – Long Term Goal : Change lifestyle habits to lose atleast 70 pounds over a 12 month period.
Short Term Goal : Client to begin a 1500 Calorie diet with walking 20 minutes per day.
Instructed patient on lower fat food choices and smaller food portions. Client will keep a daily
food and mood record to review next session. Follow-up in one week.
SOAP note Example 2 :
Patient name : Ramesh DOB : 11/11/1979
Record No. : 654321
Date : 11/11/2011
S – Mild burning with frequent urination, a thin discharge that is worse in the A.M., irritation at
the urinary opening at the tip of penis, NKA.
O – Discharge with gram stain negative for gonorrhea, showing large numbers of WBCs.
Chlamydia test is positive.
A – Non-gonorrheal Urethritis
P – Doxycycline 100mg BID for 10 days or Erythromycin 500mg QID for 10 days or
Tetracycline 500mg QID for 10 days. Increase fluid intake, avoid alcoholic beverages. Patient
education on safe sex practices.

anti-arrythmic drugs