Intro To PCM

Question 1

SOAP =

Answer 1

Subjective, Objective, Assessment, Plan

Question 2

Components of subjective

Answer 2

CC, HPI, PMH, PSH, Medications, allergies, social history, family history, review of systems

Question 3

Components of objective

Answer 3

Exam findings, lab data, radiology data

Question 4

Components of assessment

Answer 4

Basic description of the problem

Question 5

Components of plan

Answer 5

Plan of what to do about patient’s problems

Question 6

Differential diagnosis

Answer 6

The process of weighing the probability of one disease versus that of other diseases that may account for the patient’s illness

Question 7

OLD CAAARTS:

Answer 7

Onset, location, duration, characterization, associated symptoms, alleviating symptoms, aggravating symptoms, radiating pain/associations, timing, severity

Question 8

Social History consists of:

Answer 8

tobacco (quantity and duration), alchohol use (quantity and frequency), illicit drug use (quantity, frequency and route), occupation, marital status and sexual history

Question 9

Objective portion of SOAP:

Answer 9

Vital signs, heart rate, lung sounds, osteopathic structural exam

Question 10

H&P is generally done when:

Answer 10

upon hospital admission

Question 11

What is an H&P?

Answer 11

History and Physical. Contains same information as a SOAP note, just more of it…