History and SOAP Note I Flashcards
why take a history
develop relationship with patient
obtain patient info for diagnosis
medical/legal protection
billing
format vs process?
format is organized verbal and written structure of content
process is conversational in method and requires good communication/interpersonal skills
comprehensive history
detailed
for new patients, hospital admission patients, consultations, annual physicals**
problem focused history
shorter and specific
for new problems or recheck of chronic problem
whats on a comprehensive history?
patient demographics CC HPI PMH Meds Allergies Soc Hx Fam Hx ROS
patient demographics?
todays date and time
name
date of birth/age
gender
chief complaint
in patients own words
HPI
in paragraph format**
remaining history is outline format
PMH
current diagnosis chronic condition previous illnesses surgeries injuries hospitalizations pregnancy history immunizations screening tests
include dates**
medications
prescriptions
OTCs
Supplements
include dose and frequency**
allergies
meds, enviro, food
**always include reaction
social history
important is substance use:
- tobacco
- alcohol
- recreational
- caffeine
family Hx
parents, grandparents, siblings, children
review of systems
general HEENT cardiac respiratory GI GU MSK Neuro Psych Vascular Lymphatic/Hematologic/Immune Endo Repro Breast Skin
problem focused?
chief complaint HPI always review allergies and meds pertinent past medical, social, family, ROS focused physical exam assessment/diagnosis plan/treat/diagnostics
always review what on problem focused?
allergies and meds
SOAP?
subjective, objective, assessment, plan
subjective
provided by patient, historical info
objective
provided by examiner
physical observations/exams and other data
assessment
possible dx/DDx and other items to be addresed
plan
how will you investigate diagnoses and treat patient
symptoms?
subjective
-what the patient tells you
signs?
objective
-what the doctor sees or feels on physical exam
subjective includes?
CC, HPI, PMH, Meds, Allergies, Social Hx, Fam Hx, ROS
objective includes?
vitals
physical exam
laboratory testing results
what to document every time?
vitals, general assessment, heart, lungs, osteopathic exam, pertinent areas
assessment includes?
diagnosis
diff dx (3)
correlation of osteopathic somatic dysfunctions
other problems that need addressed
plan includes?
tests
treatment
patient education
follow up
if its not written?
it wasn’t done!
