2007年6月11日 星期一

SOAP

 CC pain 寂寞 失落 空虛

 

 Hx 缺口 傷口 ditto

                                                                               

 FH 疏離

                                                                               

 CXR 一顆冷藏的心

                                                                               

 Dx 憂鬱 R/O  悲傷 WNL

                                                                               

 Rx p.r.n 戀愛  kiss s/p 擁抱 q.d  談心 q.o.d  問候 BID  閱讀 NA

     p.r.n 陪伴 care closely & familiarly

                                                                               

     short term goal:to improve self-respect, ADL

   long term goal: BF

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