You are a medical assistant in a large physician practice that is going to be growing by adding additional physicians. The practice will need to hire and train quite a few new medical assistants to support these new physicians.
The office manager decides that the practice needs a process to help determine what additional training may be needed for new hires. You are part of a team that has been asked to identify a way to help new hires identify areas where they will need additional training.
Your group decides to give new hires the opportunity to demonstrate their knowledge of medical terminology and meet with the office manager to determine additional training needs based on their performance analyzing a SOAP note.
Individual Deliverable:
•Each member of the group should write a brief SOAP note of at least 4 paragraphs documenting a fictional patient visit.
•Include medical terms with suffixes, roots, and prefixes.
•Select a digestive or integumentary system patient problem that the medical terms will refer.
Go to the library, use the Web resources, and your knowledge of other medical terms to help you develop your SOAP note. Also use the library and Web resources when you encounter abbrevations or acronyms with which you are unfamiliar.
For the assessment part of your note, write a summary of the findings rather than a medical diagnosis. For the plan, you can note what medical terms seem realistic to use in terms of follow-up. The goal is to develop a document where the new hire can demonstrate his or her knowledge of medical terminology.
Also identify acronyms or abbreviations that could be misinterpreted and how you have modified your SOAP note to avoid that possible misinterpretation. For example, one of the acronyms used in one of these SOAP notes refers to the acronym SBE. This can mean self-breast examination, which is also seen as BSE (breast self-examination) or an illness called subacute bacterial endocarditis, referring to an infection of the heart. Obviously these have very different meanings.