Documentation Flashcards

1
Q

OLDCAARTS

A
  • O
    • Onset
  • L
    • Location
  • D
    • Duration
  • C
    • Character
  • A
    • Aggrivating/Alleviating factors
  • A
    • Associated symptoms
  • R
    • Radiating (can also be relieving factors)
  • T
    • Timing
  • S
    • Severity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

O in OLDCAARTS

A

Onset

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

L in OLDCAARTS

A

Locations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

D in OLDCAARTS

A

Duration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

C in OLDCAARTS

A

Character

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

First A in OLDCAARTS

A

Aggravating/Alleviating factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Second A in OLDCAARTS

A

Associated symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

R in OLDCAARTS

A

Radiating (can also include relieving factors)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

T in OLDCAARTS

A

Timing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

S in OLDCAARTS

A

Severity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

SOAP

A
  • S
    • Subjective – What the patient Says to you
  • O
    • Objective – What you Observe on physical exam
  • A
    • Assessment – Your diagnosis
  • P
    • Plan – Your treatment Plan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

S in SOAP notes

A

Subjective – what the patient says to you

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

O in SOAP notes

A

Objective – What you observe on physical exam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

A in SOAP notes

A

Assessment – Your diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

P in SOAP notes

A

Plan – Your treatment plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

VINDICATES

A
  • V
    • Vascular
  • I
    • Infectious
  • N
    • Neoplastic
  • D
    • Degenerative/Deficiency/Drugs
  • I
    • Idiopathic/Inflammatory
  • C
    • Congenital
  • A
    • Autoimmune/Allergic
  • T
    • Traumatic
  • E
    • Endocrine/Environmental
  • S
    • Something else/pSychological
17
Q

VINDICATES: V

A

Vascular

18
Q

VINDICATES: 1st I

A

Infectious

19
Q

VINDICATES: N

A

Neoplastic

20
Q

VINDICATES: D

A

Degenerative/Deficiency/Drugs

21
Q

VINDICATES: 2nd I

A

Idiopathic/Inflammatory

22
Q

VINDICATES: C

A

Congenital

23
Q

VINDICATES: A

A

Autoimmune/Allergic

24
Q

VINDICATES: T

A

Traumatic

25
Q

VINDICATES: E

A

Endocrine/Environmental

26
Q

VINDICATES: S

A

Something else/pSychological