The patient presented with pain, hematemesis, and passing flatus and motion. On examination, their vital signs and input/output charts were reviewed. Their condition on day x and any procedures were assessed. The plan was to use IV lines for fluids, medications, nutrition, blood products, analgesics, inducing anesthesia, and resuscitation needs if required. Vital sign monitoring and turning drains on or off as needed was also part of the plan. Drains could be open or closed, with closed drains either using suction or relying on gravity.

1. SOAP DR ALI
SUBJECTIVE
1. Pain
2. Hematemesis
3. Passflatus/motion
OBJECTIVE
1. Focusexamination
2. Vital sign
3. CHART
a. Vital signchart
b. Inputoutputchart
c. Medication
4. Special chart
a. Gcs chart
b. Fitchart
5. Patientidentity
6. Interpretreportlast24 hr
7. i/o
a. comment+/- balance
b. inspectdrain
ASSESMENT
1. day x
2. condition
3. procedure
PLAN
1. make
2. too manyline indicate notreadyfordischarge
3. use of ivline
a. fluid
b. medication
c. nutrition/feeding
d. bloodproduct
e. analgesic
f. induce anaethesia
g. resusneed
4. To alloworallyornot
5. Vital signmonitoring
6. To off/on_______

2. DRAIN DR ALI
1. OPEN
a. corrugated
2. CLOSED
a. Active ;chest tube/underwaterseal
b. Passive ;use gravity
3. As HO we write insertdrainas
a. Free flow,meanpassive
b. Suction,meanactive