Site Evaluation Summary

For my site evaluations, I did my surgery SOAP notes on several different types of patients. One patient had a family history of breast cancer and had a fibroadenoma that was benign years ago. A new breast mass was found on exam and a breast core biopsy was recommended. The second patient was brought into the emergency room for right upper quadrant pain for a few days after having a high fatty meal. Her right upper quadrant was tender to palpation and a CT abdomen showed gallstones in her gallbladder. Laparoscopic cholecystectomy was indicated for the patient. The third patient presented for a follow-up on her umbilical hernia repair with mesh and JP drain. Both the drain and her staples were removed that day. Finally, the last patient I wrote about was a woman who had poly-substance abuse with bilateral upper extremity infections that needed to get to the operating room to get debrided. During my first site evaluation, my evaluator told me that my SOAP notes were very sparse and that I needed to include more information like expanded vitals and imaging. I took that advice to heart and expanded every SOAP note that I made thereafter. I appreciate the constructive feedback I got from my first evaluation, because my evaluator told me that my second site visit was leaps and bounds better than my first.

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