Medical Hx Taking and SOAP Note Writing I

Question 1

What is the main thing to remember when interviewing/examining a patient?

Answer 1

if it was not documented, it was not done!

Question 2

What are the main questions to include when asking about HPI?

Answer 2

Onset, Location, Duration, Characteristics, Aggravating, Relieving factors, Timing, Severity

Question 3

What are the four main reasons to take a Hx?

Answer 3

1. develop a relationship with patient
2. obtain info to aid diagnosis
3. medical/legal protection
4. billing

Question 4

What is are the two parts taking a history can be broken down to?

Answer 4

format - organized verbal and written structure

process - conversational portion requiring good communication and interpersonal skills

Question 5

What type of history would you take when interviewing a new patient, admission of patients into a hospital, consultations, or for annual physicals?

Answer 5

comprehensive - detailed hx focused on complete knowledge of patients health status

Question 6

What type of history would you take for a patient with new problem or for monitoring a chronic condition?

Answer 6

problem focused - shorter and specific to a problem and long term care

Question 7

What are the components of a comprehensive history?

Answer 7

patient demographics, CC, HPI, PMH, medications, allergies, social hx, family hx, ROS

Question 8

How do you write the CC?

Answer 8

briefly and in the patient’s own words

Question 9

How is the history of present illness written?

Answer 9

as a condensed paragraph - telling a story

Question 10

What is included in the PMH?

Answer 10

current medications, current medical conditions, previous illnesses, surgeries, injuries, hospitalizations, immunizations, screening tests

Question 11

What are the 3 things to include in medications?

Answer 11

prescriptions - include dose and frequency
over the counter (OTC) - chronic, periodic
supplements - herbs, vit, performance enhancing /weight loss

Question 12

What categories of allergies do you include?

Answer 12

medications, environment and food. ALWAYS include reaction

Question 13

What are the categories of ‘substance use’?

Answer 13

tobacco (smoked or other, amount in pack/year), alcohol, recreational drugs, caffeine

Question 14

Why is it good to ask about family hx?

Answer 14

to get an idea of conditions that may run in the family and may be effecting your patient

Question 15

What are the components of a problem focused hx?

Answer 15

CC, HPI, allergies and medications (ALWAYS), pertinent PMH social family and ROS

Question 16

What are the four parts of a SOAP Note?

Answer 16

subjective, objective, assessment, plan

Question 17

where do you record what the patient tells you?

Answer 17

subjective

Question 18

whee do you record what you find?

Answer 18

objective

Question 19

What does the objective portion include?

Answer 19

vital signs, physical exam, and laboratory/test results

Question 20

What is included in the assessment portion?

Answer 20

• diagnosis
• differential diagnosis (list for CC)
• correlation of osteopathic SD
• other problems that need to be addressed

Question 21

What is included in the plan portion?

Answer 21

• 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?)

Question 22

What are the 4 main things to NEVER do on a SOAP Note?

Answer 22

1. document false info
2. forget to write-up
3. misplace info in wrong section
4. use white-out/scribble in charts to hide mistakes (single line w/ date and initial)