Medical Hx Taking and SOAP Note Writing I Flashcards
What is the main thing to remember when interviewing/examining a patient?
if it was not documented, it was not done!
What are the main questions to include when asking about HPI?
Onset, Location, Duration, Characteristics, Aggravating, Relieving factors, Timing, Severity
What are the four main reasons to take a Hx?
- develop a relationship with patient
- obtain info to aid diagnosis
- medical/legal protection
- billing
What is are the two parts taking a history can be broken down to?
format - organized verbal and written structure
process - conversational portion requiring good communication and interpersonal skills
What type of history would you take when interviewing a new patient, admission of patients into a hospital, consultations, or for annual physicals?
comprehensive - detailed hx focused on complete knowledge of patients health status
What type of history would you take for a patient with new problem or for monitoring a chronic condition?
problem focused - shorter and specific to a problem and long term care
What are the components of a comprehensive history?
patient demographics, CC, HPI, PMH, medications, allergies, social hx, family hx, ROS
How do you write the CC?
briefly and in the patient’s own words
How is the history of present illness written?
as a condensed paragraph - telling a story
What is included in the PMH?
current medications, current medical conditions, previous illnesses, surgeries, injuries, hospitalizations, immunizations, screening tests
What are the 3 things to include in medications?
prescriptions - include dose and frequency
over the counter (OTC) - chronic, periodic
supplements - herbs, vit, performance enhancing /weight loss
What categories of allergies do you include?
medications, environment and food. ALWAYS include reaction
What are the categories of ‘substance use’?
tobacco (smoked or other, amount in pack/year), alcohol, recreational drugs, caffeine
Why is it good to ask about family hx?
to get an idea of conditions that may run in the family and may be effecting your patient
What are the components of a problem focused hx?
CC, HPI, allergies and medications (ALWAYS), pertinent PMH social family and ROS
What are the four parts of a SOAP Note?
subjective, objective, assessment, plan
where do you record what the patient tells you?
subjective
whee do you record what you find?
objective
What does the objective portion include?
vital signs, physical exam, and laboratory/test results
What is included in the assessment portion?
- diagnosis
- differential diagnosis (list for CC)
- correlation of osteopathic SD
- other problems that need to be addressed
What is included in the plan portion?
- tests (should be specific to Dx to rule in or out)
- treatment (meds/procedures/OMT treatment)
- patient education and anticipatory guidance
- follow up plan (when where, and what next?)
What are the 4 main things to NEVER do on a SOAP Note?
- document false info
- forget to write-up
- misplace info in wrong section
- use white-out/scribble in charts to hide mistakes (single line w/ date and initial)
