Lecture 01 Soap Note Flashcards

1
Q

What are the general meanings of SOAP note?

A
S=subjective= what you learn by taking patient history
O=objective= exam including structural findings, lab, radiology data
A=assessment= what you think is going on with patient
P=plan= what you and patient agree to do about the problem (including OMT performed)
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2
Q

Subjective:

A
  • CC
  • HPI
  • PMH (other active prob)
  • PSH
  • Meds
  • allergies
  • Social/family hx
  • ROS
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3
Q

Objective:

A
  • exam findings (full or focused)
  • lab data
  • radiology data
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4
Q

Assessment:

A
  • not always a dx

- basic description of the problem (restatement of CC)

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5
Q

HPI (history or present illness)

A

-this “age/race/gender” resports…. Historical data related to CC, associated symptoms

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