Question

review the patient scenario to complete the soap note. (patient scenario: a hockey player was taking a shot on goal when his stick hit the jaw of the player who was guarding him. that player comes off the ice bleeding from the mouth, complaining of pain in his lower jaw and an inability to close his jaw (malocclusion). upon palpation by the examiner, deformity and swelling are noted. discoloration around the jaw and facial distortion are observed. the examiner suspects this athlete may have a fracture of the mandible. the bleeding is controlled, the jaw is immobilized, and the athlete is immediately referred to an emergency room.) p a o s

Explanation:

The SOAP (Subjective, Objective, Assessment, Plan) note is a common - used method in medical documentation. For the subjective part, we record the patient's own complaints like pain. The objective part includes what the examiner observes such as deformity and swelling. The assessment is the examiner's conclusion about the possible condition (like a suspected fracture). The plan details what will be done next, such as referral.
Subjective (S): The player complains of pain in his lower jaw and inability to close his jaw.
Objective (O): Bleeding from the mouth, jaw and facial distortion, deformity, swelling, and discoloration around the mandible are observed.
Assessment (A): The examiner suspects a fracture of the mandible.
Plan (P): The athlete is immediately referred to an emergency room.

Answer:

S: The player complains of pain in his lower jaw and inability to close his jaw.
O: Bleeding from the mouth, jaw and facial distortion, deformity, swelling, and discoloration around the mandible are observed.
A: The examiner suspects a fracture of the mandible.
P: The athlete is immediately referred to an emergency room.