Exam V: SOAP Notes Flashcards
SOAP Note
“Acronym for an organized structure for keeping progress notes in the chart”
Subjective
Objective
Assessment
Plan
Starts with Date and Time in the left upper corner
Required by law on every medical document
Every Note must contain the patient’s name somewhere on the sheet along with medical record number
Electronic record
Printed sticker
Hand written
CODIERS
Chronology Onset Duration Intensity Exacerbation Remitting Symptoms associated
Chronology
Have you had this before When did you have it How many times What did you do for it Did you see a physician What did they do Did that work well
Onset, Duration, and Intensity
Onset
When did this start
What were you doing
Duration
How long does it last
Has it changed
Intensity
How bad is it
1-10 scale
Exacerbation and Remission
Exacerbation
What makes it worse
Remission
What makes it better
IF a drug made it better: what drug, how much, how often
SMASH FM
Surgical history Medical history Allergies Social history (see next slide) Hospitalizations Family history Medications
Social History
FED TACOS
Food (diet) Exercise Drugs Tobacco Alcohol Caffeine Occupation Sexual history
Plan
MOTHRR
Medications OMM Tests Holistic/Humanistic Referrals Return
Subjective Data
CODIERS SMASH FM FED TACOS
What the patient tells you
You are not responsible for making certain it is absolutely correct
You ARE required to record it as accurately as possible
Chief Complaint= simple, best if in the patient’s own words
History of Present Illness
CODIERS – Paragraph format; chronology all together
Symptoms Associated
Pertinent Positives- “patient states”
Pertinent Negatives- “patient denies”
SMASH FM – Bulleted format
Objective Data
Vital Signs, Physical exam, test results Facts that you have determined YOU ARE responsible for the veracity Always record this accurately NEVER record anything you did not actually check Outline format to make it easy to read
Physical Examination- bulleted with headings with vitals and general assessment
Then work Head to Toe HEENT – blah blah blah Respiratory – yada yada yada Cardiac – etc. etc. etc. Abdominal Musculoskeletal Neurologic Genitalia
Test results
Assessment
Differential Diagnosis
Primary diagnoses first
You must commit to some kind of primary diagnosis even if it comes out “I think you have”
First choice cannot be “Rule out” or “Doubt”
Second and third may be “Rule out”
Label unlikely diagnosis as “Doubt”
Must have 3 diagnoses related to the CC to break even, a 4th will get you one point added (COMLEX)
Secondary diagnoses next
These do not relate to the CC
Any other diagnosis you intend to address
Hypertension, Diabetes, Bee sting allergy
Plan for Primary Dx
MOTHRR
Medications – OTC/prescriptions
OMM – not all cases get OMM; may put “will perform OMM next visit”
Tests – Labs/Imaging
Holistic/Humanistic: rest, heat, elevation, not eating before bed; offering to contact family members
Referrals – may also be left out
Return to office – follow-up, call instructions
ALWAYS have a return plan
Hospital admission counts as “Return”
How to End a SOAP Note
Your signature and date directly underneath last line so no one can accidentally write in your section
Brief Pre-Op Note
Date/Time:
Patient ID: one sentence describing significant PMhx and procedure
79 y/o CF with h/o htn, dm for lap chole Brief hx and physical (See complete pre-op H&P) Meds: Allergies: Labs: including results of pregnancy test CXR: EKG: Operative consent: signed Legible Name and Signature
Brief Operative Note
Date/Time:
Surgeon: Assistant: Pre-op dx Post-op dx Procedure Anesthesia: type i.e. general via ETT, via mask, spinal, regional, local Fluids EBL: U.O. Drains/tubes Post op condition Legible Name and Signature
Operative Note: dictated by surgeon directly afterward; more in depth than the above
