Apie Or Soap Chart Note : Scenario Jonny, Aged 3, For The First Time Prior To His X-Ray

APIE Chart Note:Assesment- The patient seemed to be in distress at the time before their scheduled assesment. It would seem the patient is attached to the parent and lashed out physically at health staff attempting to calm him. Physical discomfort from the abdominal region could be the main cause for their crying as they kept clutching at this area during the entire period. Given his age, the patient may also have been experiencing an anxiety shock in addition to parental attachment that lead to the lashing out at medical staff. The patient’s attempts at physical exertion seem labored and very exhaustive, an indication of either having made attempts to free themselves for a while or a lack of sleep due to medical distress. Planning – make attempts to calm the patient down before heading to the X-Ray room for assesment. Confer with the parent on the most plausible means of familiarizing with the patient to reduce their experience of anxiety. Find appropriate toys for the patient that would mitigate their fear but not interfere with the integrity of the procedure. Devise a method to explain the procedure to the patient as their cooperation is important in the examination’s outcome.