Lecture 2 Flashcards
0
Q
Basic Outline of Medical Record
A
Identification (who all is in room) Informant Chief Complaints History of Present Illness (include PROS) Medications Allergies Past Medical and Surgical History Family History Personal history Social History Review of Systems Preventative Care Service Physical Examination Laboratory and Imaging Services Assessment Plan
1
Q
SOAP
A
Format for clinical note-taking
Subjective - info, absence/presence of symptoms, patient offered
Objective - Findings, direct observations (see-hear-touch-smell)
Assessment - Interpretation, Conclusions, Rationale, Diagnostic Possibilities, present and anticipated problems, ongoing problems, “What do you think?”
Plan - Develop a plan for each problem; test, treatments, education
2
Q
Sign vs. Symptom
A
Sign - observable, specific, measurable; (vital signs)
Symptom - subjective, usually patient aware; (“pain”)
3
Q
“S” Part of SOAP - Abbreviations
A
"CC" HPI - includes PROS (pertinent review of systems) MEDS PMH/PMHx PSH/PSHx FMH/FMHx SOCH/SOCHx ROS
