Lab #1: History taking and SOAP note Flashcards
mnemonic for history of the chief complaint (Cc)/ history of present illness (HPI)
CODIERS: chronology, onset, description, intensity, exacerbation, remission, social/psychological history
Chronology questions
Does it follow any time pattern, how long does it last?
Onset questions
when did it start, was it constant/intermittent, gradual/sudden?
Description questions
what is the pain like, e.g. is it sharp, burning, dull?
Intensity questions
how would you rate the pain on a scale of 1-10?
Exacerbation questions
is there anything that makes it worse?
Remission questions
Is there anything that makes it better?
past medical history (PMhx) mnemonic to use
MIMASH: medical illnesses, injuries, medications (Meds), allergies (All), surgical history (PSHx), hospitalizations
what do you ask about after you ask about the history of the chief complaint, and the past medical history?
family medical history (FHx), social history (SocHx), health care maintenance (HCM), review of all the systems ROS (ask 2 important questions per system)
SOAP note abbreviation
Subjective, objective, assessment, and plan
what goes at the end of a SOAP note?
signed and name printed with title, with date and time
subjective part of SOAP note
history obtained from the patient written organized
chief complaint
“what the patient complains about in a few words”
Example: “My chest hurts”
HPI: history of present illness
bulk of the history; what is going on with the current problem
written in a short succinct paragraph, bullet points recommended, use medical abbreviations
HPI acronyms for questioning
SAMPLE: symptoms, allergies, medications, past history, last intake/output, events leading up to the problem
OPQRST: onset (what they were doing when it started/got worse), palliative (what makes it better), quality, radiates/refers, severity, time (onset, duration, frequency, progression over time)
asking about PMHx
ask if the patient has any medical problems or illnesses. Be sure to ask specifically about common medical diseases, like HTN, heart disease, stroke, lung disease, DM, cancer, obesity, depression, dementia
asking about medications
ask about all current prescriptions and non-prescriptions, medications including dosage, frequency, compliance
asking about allergies
ask about allergies to medications and foods or environmental, and ask what happens
asking about FamHx
ask about diseases in the family, parents, their age, deceased, why? ask about siblings and children
asking about SocHx
ask about their occupation, home life, status, exercise, diet, hobbies. Ask about sex, if protection used, STI Hx, gender preference; ask about drugs; ask about alcohol (how much, how often, for how long); smoking (how many packs a day for how many years)
asking about HCM
ask when their last physical was, flu vaccines/IMM, mammograms, colonoscopies
common ROS questions for constitutional
wt loss, fever, night sweats, fatigue, wt gain
common ROS questions for HEENT
vision changes, double vision, hearing loss, tinnitus, congestion, nose bleeds, sore throat, difficulty swallowing
common ROS questions for cardiology
chest pain, palpitations, syncope
common ROS questions for chest
cough, trouble breathing, wheezing
common ROS questions for GI
vomiting, diarrhea, abdominal pain, constipation
common ROS questions for Ext
joint pains, cramping, swelling
common ROS questions for neuro
headaches, dizziness, numbness, weakness
common ROS questions for skin
rashes, hives, lumps
Objective
vitals, general assessment, skin, HEENT, CVS, Resp, Ab, Ext/Back, Neuro, genital, OMM
sometimes the physical will be focused based on the history, ONLY document what you actually observed
do not document “normal,” need to document specific negatives
what are the vitals?
BP, Ht, Wt, BMI, HR, RR, Temp, PulseOx
Review of systems
organized questions about each organ system to elicit other problems that may have not been elicited in the HPI
can’t document that the review of systems was negative
Assessment
your differential diagnosis of what is going on based on the history and physical; your impression of the problem
list in order of most likely to least likely, at least 3 possibilities and the osteopathic D
do not use words “rule out, consider, possible, probable)
Plan
what is going to be done about the most likely diagnosis
labs, imaging, other tests, medications, lifestyle changes, referrals, follow-up, osteopathic treatment
