The SOAP Note Diaries: Introduction

The SOAP Note Diaries: “ER docs in a cannabis world”

Introduction:

Dr. Khalsa and I were initially nervous to take the leap and start specializing in medical cannabis.  We knew some of our colleagues would look down on us.  However a part of us always knew we were supposed to advocate for this patient population.  People who could genuinely benefit from medical cannabis.

This blog became a way that Dr. Khalsa and I could share our stories with you from working in the emergency department.  We encounter so many different people who are battling severe diseases and we feel they deserve access to medical cannabis without stigmatization.

They deserve to be treated as patients who are seeking medications that work best for them.

They deserve to be treated not as drug addicts or uneducated people but as patients who are looking for a different approach to their treatment plans, when nothing else seems to be working.

These are their stories and we hope we can do them justice.

Our hope is for this blog to bring a new perspective to the table.  Thank you for keeping an open mind and for taking the time to read our stories.

What is a SOAP note?

A SOAP note is used by many physicians to document the patient’s encounter.  It is a shorter simplified note made up of 3 parts.

“Subjective” explains why the patient is there.  This part is told completely from the side of the patient.  Why are they here today?  What is bothering them?  What makes it better?  What makes it worse?

In our blog, this is where we tell the patient’s story.  All names are fictional and specific details about the case have been changed to protect the patient’s privacy.

“Objective” is the physician’s evaluation of the patient, including a physical exam. It states the facts of what they have observed with the patient and their clinical findings.

In our blog, this is where we review the literature on medical cannabis related to a specific disease process.  We talk about what the studies showed, any weaknesses in the literature and any future research that is pending.

“Assessment and Plan” is the part where a physician documents what he/she thinks the diagnosis may be and his/her plan for further evaluation or treatment.

In our blog, this is where we summarize our thoughts on the disease and the effectiveness of medical cannabis.  They are our “take home points.”

‘Final Impression” is where the physician documents his/her final diagnosis and thoughts.

In our blog, this is where we express our final thoughts about the patient and topic at hand.

We always cite recommended resources and additional reading materials on the subject matter at the end of each blog post.

Thanks for reading!

Drs. Khalsa and Ratnabalasuriar

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