CM&R Flashcards
SOAP
S: CC, HPI, Allergies, Meds, PMH, PSH, FH, SH, ROS
O: exam
A: summary, differential diagnosis, status (new, controlled, uncontrolled)
P: Plan “TTFP”
Subjective
CC, HPI, Allergies, Meds, PMH, PSH, FH, SH, ROS
associate symptoms
Pertinent symptoms but not a complete ROS
Complete ROS: 2 symptoms noted for each system
OPQRST
O1 P3 Q1 R1 S6 T7
Onset Provoking factors (worse) Palliating factors (better) Prior episodes “Quality” Radiation (from what primary location) Severity (1-10/ or affecting ADLS) Symptoms associated Setting in which symptoms occur Stress Sleep Sick contacts Timing Triggers- originally brought this on Trending-changing over time Trauma- trauma to the area Travel Temperature Treatments- what have they done
4 sources of allergies
medication, food, contact, environment)
allergy vs intolerance
Allergies typically occur within an short time frame of exposure, involve immune system
4 basic vital signs
HR, BP, RR, temp
HR normal range
60 to 99
RR
12 to 20 breaths per min
Temp
97 to 100.3 F
36.1 to 37.9 C
BP
<120/80
stage 1 >140/90
stage 2 >160/100
other common vital signs
BMI, height, weight, pulse ox, pain
plan
treatment, testing, follow-up, patient education
assessment
summary statement, differential diagnoses, other diagnoses, lifestyle diagnoses, OMM diagnoses
semantic qualifiers
Onset Timing or Progression Site/Location Presence of pain Triggers of symptoms Other
