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ScribeU > OP 1: Clinic Flow & SOAP > Flashcards

OP 1: Clinic Flow & SOAP Flashcards

1
Q

Chief Complaint (CC)

A

Main reason fro patient’s visit

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2
Q

Electronic Medical Record (EMR)

A

Electronic medical record

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3
Q

Subjective

A

Feeling (Patient POV)
Ex: HPI & ROI

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4
Q

Objective

A

Factual finding from the provider
Ex: Vitals, Orders & Results, PE

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5
Q

Pain

A

Patient’s feeling of discomfort (Subjective)

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6
Q

Tenderness

A

Doctor’s findings of reproducible pain (Objective)

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7
Q

Acute

A

New onset, likely concerning

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8
Q

Chronic

A

Long-standing, not of direct concern
For > 3 months

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9
Q

Types of Patients

A
  1. New
  2. Established
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10
Q

New Patient

A

A patient that has never been seen at the clinic OR was seen > 3 years ago
- No previous records
- Longer visit
- Detailed chart

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11
Q

Established Patient

A

A patient that has been seen at the clinic (by any provider) within the last 3 years
- Previous records available
- Shorter visit
- Concise chart

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12
Q

Types of Visits:

A
  1. Diagnostic
  2. Health Management
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13
Q

Diagnostic Visit

A

CC: New symptom
Goal: determine cause of problem & appropriate treatment

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14
Q

Health Management Visit

A

CC: Routine physical or management of chronic problems
Goal: preventative care and/or assessing progress of ongoing medical problems

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15
Q

Clinic Flow

A
  1. Check-in and Chief Complaint
  2. History & Physical
  3. Orders & Results
  4. Assessment & Plan
  5. Check-out
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16
Q

Check-in & CC

A
  1. Patient arrives and is assigned a room
  2. Nurse or MA Assessment
  3. Vital Signs
17
Q

Vital Signs

A
  • Heart Rate (bpm)
  • Blood Pressure (mmHg)
  • Respiratory Rate (RR)
  • Temperature (Celsius or Fahrenheit)
  • Oxygen Saturation (SaO2 %)
18
Q

History & Physical

A

Before entering room:
- Provider reviews patient’s medical records (assessment, plan, lab results)
History of Present Illness (HPI)
Review of Systems (ROS)
Physical Exam (PE)
DDx: Differential diagnoses

19
Q

Orders & Results

A
  1. Lab Studies
  2. Imaging Studies
  3. Procedures
20
Q

Lab Studies

A
  • Blood work
  • Urinalysis
  • Microscopy
  • Cultures
21
Q

Imaging Studies

A
  • EKG
  • XR
  • CT
  • Ultrasound
22
Q

Procedures

A
  • Sutures
  • Joint Reduction
  • Splints
23
Q

Assessment

A

List of current diagnoses & summary of the visit

24
Q

Check-out

A

Either discharged or sent to ED (Emergency Department)

25
Q

Plan

A

Instructions for lifestyle changes, medications, and follow-up

26
Q

SOAP

A

Subjective
Objective
Assessment
Plan

ScribeU (6 decks)

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