Interviewing and Patient History Flashcards
“Where would you say the pain is coming from?”
Location
“Describe the pain. Is it sharp or throbbing?”
Quality
“On a scale of 1 to 10, how would you rate the pain?”
Severity
“Does the pain decrease if you hold it still?”
Modifying factors
“Is anything else happening with the pain? Headache or fatigue?”
Associated symptoms
“What were you doing and where were you when the pain began?”
Onset/Setting
“Has this pain happened before?”
History
“Do you have any idea what might have caused this pain?”
Meaning to the patient
What goes in the heading of a SOAP note?
Patient name, age, chief complaint, allergies
What goes in the subjective section of a SOAP note?
Full sentences including the patient interaction, the 8 attributes of the symptom, and all history
What goes in the objective section of a SOAP note?
A list of allergies, medications divided by type, vitals/physical examinations, and test results
