EFFECTIVE COMMUNICAT TICE SOAP Note Practice #1 Student Instructions: Carefully examine the scenario below of an interaction between a patient and a healthcare provider. Gather all the important information needed to write a SOAP note. Refer to your textbook and class notes, if needed. Using a black or blue inker to follow the guidelines and standard abbreviations where applicable. Use today Linda Mitt, a 42-year-old female, is in a medicine unit recovering from a lower gastrointestinal bleed. She is a 1 assist transfer using a transfer belt and 2 wheeled-walker. For the most part, she has been staying in bed due to general weakness. This is because she was not able to eat the last two days waiting for a colonoscopy to be done. Her scope was done last night. And today was the first day she was able to eat some breakfast. Linda calls for assistance to her bedside commode. You help her stand up. She is swaying slightly side-to-side. She states, “I’m feeling really dizzy. I see stars. I think l’m going to faint.” You quickly sit her back on the bed. You observe that she is pale-looking. When you touch her forehead, it feels cool and clammy. For a few seconds, she went unconscious, as she was unable to respond to your question. She quickly regains her consciousness. You press your patient’s call bell. A voice comes on the intercom speaker and you ask for a nurses’ help. The nurse comes into the patient’s room and takes a set of vital records. Temperature 37 degrees Celsius, blood pressure
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