Medical Chart Flashcards
Chart Flow
Subjective > Past History > Physical Exam > Course/Assessment > Diagnosis/Discharge and Plan
-remember subjective = what patient says, objective = what doctor and test results say + diagnosis
(tenderness is objective, pain is subjective)
SOAP = subjective, objective, assessment, plan
assessment = how you assess patient info, what find in physical exam, what labs/procedures/images were done, results
–in ER, you call this “ED course (of action)”
(ER = emergency room, ED = emergency department)
Plan = details of diagnosis, plan for treatment, follow-up appointments
-usually home care or info for hospital staff
Emergency/Urgent Care/Hospital
- focus on what is newly wrong
- what happened, lab/test results, plan
- labs tend to give same-day results b/c more severe
Outpatient
- notes are more whole-picture
- usually don’t have same-day lab/imaging
- focus on chronic things mainly
Summary of chart flow
Who gave this info?
- patient = subjective, provider = objective
- info found on physical exam? yes = physical exam, no = HPI
- Order for something or result? = assessment/ED course
- diagnosis, where patient is going, or plan of care = plan
Subjective
CC, HPI, ROS, Past history
CC = chief complaint
—-main reason for visit
HPI = history of present illness
- —story of CC ONLY
- —contains elements
ROS = review of systems
- —symptoms mentioned in HPI + anything else going on in body
- —-basically all the symptoms
Past history (medical)
also PE = physical exam, ex) abdominal tenderness
CC
chief complaint
Pt
patient
c/o
complains of
y/o
year old
c
with
s
without
CP
chest pain
SOB
shortness of breath
DM, HTN, HLD, CAD
diabetes mellitus
hypertension
hyperlipidemia
coronary artery disease / heart disease
