Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:Management Plan SOAP Format Problem 1: Polydipsia, polyuria Dx : Blood sugar, hemoglobin A1c, urinalysis Tx : Diabetic diet, exercise prescription Pt. education: Meet with diabetic educator, referral to local diabetes group Problem 2: High blood pressure Dx : EKG, urinalysis, serum electrolytes Tx : Low-salt diet, exercise prescription, diuretic Pt. education: Hypertension handout, list of useful websites 10
Slide notes:10 Heres a sample of such a plan. The words diagnosis and treatment are replaced by the term management plan as a reminder that an exact diagnosis is often not available when the plan is madeand may never be. In many cases, the outcome is not a treatment plan but a management planone that includes diagnostic testing or monitoring; other elements of management besides treatment, especially for conditions that are not treatable; and patient education and engagement.