Hx and SOAP Note I - Luke (done, barring additions) Flashcards
1
Q
Why take a history?
A
Relationship with patient, billing, aid in diagnosis, medical/legal protection.
2
Q
What types of patient would require a comprehensive history
A
New patients, hospital admissions, annual physicals, consultations.
3
Q
What types of patients would require a focused physical>
A
New problems, recheck of chronic problems.
4
Q
Components of history
A
Patient Demographics CC- Chief Complaint HPI- History of Present Illness PMH- Past Medical History Medications Allergies (must have reaction) Social History Family History ROS- Review of Systems
5
Q
Past medical history components.
A
Current medical diagnosis or Chronic conditions Previous major illnesses (including childhood) Surgeries Injuries Hospitalizations Pregnancy history Immunizations Screening tests
6
Q
Why should you ALWAYS review allergies
A
Because I said so, also always pertinent to tests/medications.
7
Q
Components of the plan.
A
Tests, treatment, patient education, follow up.
8
Q
Not documented=
A
NOT DONE
9
Q
Do of SOAP note
A
Document, sign note, CC in patients words.
10
Q
Don’ts of Soap note
A
Falsify info, misplace info, forget if write up patient info.
