Lecture 1

Question 1

Now if Ron is in the ICU intubated and I’m in the chart and I see penicillin rash…what section would that go it would be objective because its coming from the chart

Question 2

So subjective is anything that your getting from your patient

Question 3

With allergies there are two parts that are important to include…what patient is allergic to and what happens

Question 4

What’s the difference btwn no known drug allergies (NKDA) and unknown drug allergies? With unknown drug allergies you don’t know that means either you forgot to ask or if the patient doesn’t know then you have to be really specific so in that section of allergies you would say patient does not know allergy history as opposed to me saying I don’t have any allergies that’s no known drug allergies and if you were to document on penicillin allergy you can either write out penicillin or abbreviate it and then in parathesis its reaction

Question 5

Chief Complaint is in quotes…if you don’t have quotes from a pt then you don’t have a chief complaint so leave it out since you don’t have one

History of Present Illness- 58 year old female presents to clinic with a headache

Past medical history (PMH)- if pt has hypertension you need to write hypertension…if you write high blood that’s a rewrite ☹

Family History (FH): Mother has colon, history of MI at age 74…MI is myocardial infarction…if you say history of heart that’s wrong!

Social History (SH): who lives at home with them are they working

Question 6

Review of systems (ROS): head to toe (see pocket card book)…lists a series of questions that you would be asking the pt…when you put this in a SOAP note it has to be in these systems…its not just a narrative paragraph…do you have to include all of them..no include the ones that you have and there will be soap notes where you don’t have a review of systems and there will be notes when you do

Question 7

If I ask Ron what medications are you taking or he hands me a med list that’s going to go in subjective

Question 8

If I’m taking a med list from a chart or a medical record that’s going to go in objective

Question 9

Always include generic names and don’t have to include a brand name EVER IN SOAP Note. If you choose based on your own style…spelling counts ☹

Don’t ever use abbreviations like qd or sq…its an automatic rewrite…these are not safe abbreviations…so if its daily you can write once daily or daily…if pt is taking insulin or some type of injection that’s subcutaneous… Sub cut is acceptable or write out subcutaneous but SQ is not acceptable ☹

If it’s an inhaler have you have to list route on soap ex: albuteral 90mg MDI, inhale 1 puff in each nostril po daily