SOAP Flashcards
Problem list contains:
objective findings that include:
Impairments
Activity Limitations
Participation Restriction
The problem list can contain findings that may be
Active or Inactive
The findings in the problem list can be marked as
Controlled
Resolved
Unresolved
Daily Progress notes are written every
every 6 days
Advantages of POMR
Organized and structured medical info
Includes a comprehensive list of pt’s problems
Discusses each pt problem
Provide separate care for each problem
Provide specific plan for each prolem
Chronological sequence of interventions
Disadvantages of POMR
Separates each problem of the pt
Time consuming
What are the types of notes
Initial Evaluation/Initial Note
Progress note
Discharge note
Components of patient management process
Examination
Evaluation
Diagnosis
Prognosis
POC
ABCs of writing a medical record
Accuracy
Brevity
Clarity
Rules for using hyphen
Should be avoided at all times; must be used only in recording ROMs
Rules for using semi-colon
Substitute for the word “states”
Rules for using colon
Substitute for “is”
The process of signing patient care notes
authentication
How to correct errors?
strikethrough the error using a single line then write last name + name initials, date, and signature above
Two important components of writing verbal orders
Time/Date/Order
v.o Physician’s name/Therapist’s name, (PT/OT)
Known as the “identifying information”
Demographics
What are the information included in HPI?
Other treatment team
Onset
Prior Hx of similar problems
Pt’s functional capacity
What are the information found in social hx
cultural and religious beliefs
social support
how the ppl around the pt can support them
What are the information found in living environment?
Assistive devices used
House modifications
Past use of community services
What can be found in the general health status section?
Pt’s rating of his or her health
Subjective and verbatim
Can be rated via good, fair, or poor
Social health habits
Vices
Exercises habits
Lifestyle
MedSurg can be noted as
Resolved
Unresolved
Controlled
What are the bodily systems under the Review of Systems
Cardiovascular
Integumentary
Musculoskeletal
Neuromuscular
Communication style
How can ROS be noted?
Impaired or unimpaired
What are the information found under the Cardiovascular system?
Vital signs
What are the information found under the Integumentary system?
Integrity/Continuity
Color
Pliability
Texture
What are the information found under the Musculoskeletal system?
Gross Symmetry
Gross ROM
Gross MMT
Ht and Wt.
BMI
What are the information found under the Neuromuscular system?
Gait
Locomotion
Balance
Motor function
What is assessed in the pt’s locomotion?
Transfers
Bed mobility
What are the information found in the Motor function of a pt?
Motor control
Motor learning
What are the information found under communication style/abilities ?
Affect
Cognition
Learning barriers
Learning style
Educational needs
How to assess the pt’s cognition?
Level of Consciousness
How to assess the pt’s educational needs?
Focus on what the pt needs to be educated on
Mnemonics for auscultation
APMT
2254
RLLL
Mnemonics for palpation
APMT
3344
LLRR
