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
2
Q
O in OLDCAARTS
A
Onset
3
Q
L in OLDCAARTS
A
Locations
4
Q
D in OLDCAARTS
A
Duration
5
Q
C in OLDCAARTS
A
Character
6
Q
First A in OLDCAARTS
A
Aggravating/Alleviating factors
7
Q
Second A in OLDCAARTS
A
Associated symptoms
8
Q
R in OLDCAARTS
A
Radiating (can also include relieving factors)
9
Q
T in OLDCAARTS
A
Timing
10
Q
S in OLDCAARTS
A
Severity
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
12
Q
S in SOAP notes
A
Subjective – what the patient says to you
13
Q
O in SOAP notes
A
Objective – What you observe on physical exam
14
Q
A in SOAP notes
A
Assessment – Your diagnosis
15
Q
P in SOAP notes
A
Plan – Your treatment plan
