Instructions:
Part 1: List each of the red medical definitions from the scenario and tell what the corresponding medical term is for each. Example: a surgical opening in the bowel that allows stool to flow into an attached bag – ostomy.
Part 2: Use the information gathered to rewrite the note in medical terms, including what the physician understood to be the problem, what was found in the physical exam and tests, the diagnosis, and the plan of care. These steps represent SOAP therefore, the SOAP labels should be included on each part.
Case Study:
You are a medical scribe working in the emergency department. Your patient is a 31-year-old female named Brenda.  The following is Brenda’s explanation of events leading up to her trip to the emergency department.
“About 20 minutes after dinner, I was sitting in the recliner watching TV with my family, and I suddenly had sharp stabbing pains in my chest.  I told my husband I thought I was having a heart attack, so he called 911.  By the time the ambulance got there, the pain had moved from my chest to between my shoulder blades.  It was unbearable, a 12 on a scale of 1-10.”
Brenda’s physical exam showed some tensing of her abdominal muscles and pain when the physician pressed on her stomach on the right side just below the ribs.  On a hunch, he asked Brenda if she and her family had eaten a greasy meal for dinner, and a surprised Brenda admitted that they had fried chicken.  After the ECG found no abnormalities, the physician ordered a scan of Brenda’s abdomen using high-frequency sound waves to visualize her internal organs.  Just as expected, Brenda’s gallbladder was swollen and contained many small stones. No other abnormalities were found on Brenda’s exam.
A surgeon was called, and she decided to remove Brenda’s gallbladder using a minimally invasive surgical method with a laparoscope.  She also explained that since the stones were so small, she needed to be sure that none of them had pushed into the ducts that carry bile from the gallbladder and live to the small intestine, so she would need to inject some dye into those ducts and shoot an X-ray to make sure.  Brenda was instructed that after the surgery, she should avoid fatty foods, and would need to follow up with her surgeon in 2 weeks.