Barriers to Interpersonal Communication and SOAP Approach for Documenting Patient Data

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Advanced Health Assessment
Person #1: 16-year-old white pregnant teenager living in an inner-city neighborhood.
Barriers to Interpersonal Communication
The possible barriers to effective interpersonal communication include the use of medical jargon that the patient will have a hard time comprehending. However, the patient is under the age of 18 years old and lives in an inner-city neighborhood, so communication should be age-appropriate and can be understandable to common people who are not in the medical field. Another possible barrier is when the patient feels judged by the interviewer/clinician given the social stigma that is attached to the situation, so this should be avoided to prevent the patient from reacting defensively or angrily. Also, asking interview-like questions may be threatening or overwhelming for the patient, so rapport should be built first so that the teenage patient will be able to honestly and comfortably share her answers and other additional information that may be beneficial in her history-taking and current case. Lastly, an environmental setting that will keep the patient’s privacy should be prioritized to encourage honest conversations with possible sensitive topics (Ali, 2017).
Procedure and Examination Techniques
As soon as the clinician has the chance to observe the patient, the inspection should already begin. The different senses and body systems should be observed such as vision, hearing, manner of locomotion, asymmetries, and possible visual signs of injury or trauma. The patient is still a teenager, and it would be beneficial for the patient to have an adult with her during the whole procedure and interview. Auscultation should also be done during the physical assessment for both the mother and the baby inside the mother’s abdomen.
Subjective, Objective, Assessment, Planning (S.O.A.P.) Approach
The history of pregnancy and the level of care and awareness given to the patient should be evaluated. In the documentation, the patient should be asked about any health issues that she is experiencing aside from being pregnant. During the examination and interview, the possibility of domestic abuse and substance abuse should be checked subtly and non-offensive through subjective and objective information. The welfare of the teenager should be checked with some inquiries about her home environment and lifestyle. The patient’s vital signs should be included in the objective evaluation, including her height, weight, and information about her last menstrual period. Aside from these, laboratory tests should also be included such as ultrasound, urinalysis, blood tests, etc. (Toney-Butler & U...