Interview Basics

Question 1

SOAP note

Answer 1

Subjective
Objective
Assessment
Plan

Question 2

Subjective

Answer 2

Chief complaint (CC)
history of present illness (HPI)
Review of systems (ROS)
Past medical history (PMH)
Past surgical history (PSH)
Medications (meds)
Allergies (ALL)
Family history (FH)
Social history (SH)

Question 3

Objective

Answer 3

Exam findings: full vs focused
Lab data
Radiology data

Question 4

Assessment

Answer 4

Not always a diagnosis
Basic description of the problem
Differential diagnosis: probable cause of the assessment, listed in order of most likely to least likely

Question 5

OLDCAAARTS

Answer 5

Onset
Location
Duration
Characterization
Alleviating factors
Aggravating factors
Associated symptoms
Radiation
Timing
Severity

Question 6

Social history

Answer 6

FEDTACOS
Food
Exercise
Drugs
Tobacco
Alcohol
Caffeine
Occupation 
Sexual history/support/spirituality

Question 7

Must ask for medications

Answer 7

Rx
OTC
Vitamins
Must get dosages and how often taken
Why they take it
Make sure to check on BC for women

Question 8

Allergies must ask

Answer 8

Food
Environmental
Medicational allergies
Must record reaction

Question 9

Alcohol CAGE questions

Answer 9

Cut back
Annoyed when people talk about your drinking
Guilty about drinking
Steady your nerves (Eye opener)

Question 10

Safe drinking limits

Answer 10

Women and over 65-no more than 3 drinks on any single day and no more than 7 drinks per week
Men-no more than 4 drinks on any single day and no more than 14 drinks per week
Beer=12 ounces
Wine= 5 ounces
Liquor=1 ounce

Question 11

Five P’s of sexual history

Answer 11

Partners
Practices
Prevention of pregnancy
Protection from STIs
Past history of STIs