Intro to SOAP note

Question 1

SOAP stands for …

Answer 1

subjective
objective
assessment
plan

Question 2

subjective section contains …

Answer 2

CC (chief complaint)
HPI (history of present illness WITH associated symptoms)
ROS (review of systems)
Meds
Allergies
PMH (past medical history)
PSH (past surgical history)
FH (family history)
SH (social history)

use these abbreviations as your headers on your SOAP note

Question 3

CC

Answer 3

chief complaint – in patient’s own words on why they are here

Question 4

HPI

Answer 4

start with opening statement with pt’s demographics, then include 4 questions about their annual exam or questions using the mnemonic OPQRST for a problem focused visit

Question 5

allergies

Answer 5

4 items, must use all 4 individually
(meds, food, contact, environmental)

Question 6

PMH

Answer 6

all significant past and present medical diagnoses, date dx, controlled/uncontrolled. Past hospitalizations and preventive testing (vaccines, colonoscopy, mammo, pap…)

Question 7

PSH

Answer 7

all general or other significant surgeries, date, location, outcome

Question 8

FH

Answer 8

2-3 generations with age, health status, significant diseases, and if dead. Document if unknown

Question 9

SH

Answer 9

Habits (drugs, alcohol, tob, diet/caffeine, exercise), Hobbies: (sexual history -# partners, birth control methods…, tattoos, religious beliefs, hobbies; and Home (partner status, living where, kids? Pets? Safe at home?, occupation, stress and sleep)

Question 10

ROS

Answer 10

full 12 system review for general screening annual exams or with complex cases (ie in hospital or ED)

must ask total 3 questions for each system

Question 11

after establishing CC, annual exam asks 4 questions:

Answer 11

-when was last physical?

-did they perform any testing / what did they find?

-did anything change since then?

-do you have any concerns?

Question 12

problem visit - HPI questions:

Answer 12

OP(T)QRST

onset

provoking factors / palliating factors / prior episodes

timing (duration / frequency / trends), triggers, treatment tried

quality

radiation

severity (0-10 scale only used for pain), ADLs / sick contacts / symptoms associated

trauma / travel

Question 13

3 questions to ask per system in ROS

Answer 13

1 open-ended question
ex. “what concerns, if any, do you have with your heart?”

followed by 2 closed-ended questions (yes or no questions)
ex. “do you have any chest pain?” “any heart racing?”

Question 14

12 ROS systems

Answer 14

General, HEENT, Neck, Respiratory, Cardiovascular, Gastrointestinal, Genital, Urinary, Skin, Musculoskeletal, Psychiatric, Neurologic

Question 15

5 subsections of HEENT

Answer 15

Head
Eyes
Ears
Nose
Throat/mouth

Question 16

documenting allergies:

Answer 16

ex.
NKDA and NKA to foods, contact, environment.

for positives = NKDA and NKA to foods, contact, or environment, except for shellfish (anaphylaxis).