Lecture 6

Question 1

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 2

____________ 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

Answer 2

Chief complaint

Question 3

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

Question 4

____________ (PMH)- if pt has hypertension you need to write hypertension…if you write high blood pressure that’s a rewrite

Answer 4

past medical history

Question 5

Food,______,salt,physical activity, and alcohol all have an impact on blood pressure

Answer 5

weight

Question 6

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

Answer 6

Social History

Question 7

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

Answer 7

Family history

Question 8

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 9

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

Answer 9

subjective

Question 10

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

Answer 10

objective

Question 11

Always include generic names and don’t have to include a brand name EVER IN SOAP Note.

Question 12

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

Question 13

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