SOAP Flashcards
Who provides subjective information?
Patient, family, or EMS
What info is included in subjective?
CC, HPI, PMHx, ROS, (PMH, PSH, FHx, SHx) part of HPI ()
CC
Subjective. Main reason in ER, cannot be a cause, action, or diagnosis
ROS
Subjective. Contains all symptoms admits/denies including chief complaint.
MDM
Ddx, lab results, procedures, rechecks/consults
What are rechecks?
Every time a physician re-enters the room. Document every recheck
Assessment is..
The final diagnosis
What needs to be recorded at discharge?
Diagnosis, disposition, condition, instructions, prescriptions, f/o instructions, return to ER warnings.
What needs to be recorded during admission?
Admitting physician, consulting physician, condition, critical care time, floor.
What are the 8 elements of HPI?
Timing (onset), location, duration, context (what doing when started), severity, quality (type of pain), modifying factors (makes better/worse/no change), assoc. signs and symptoms.
ROS directly correlates with what element of the HPI? What else does it contain?
Assoc. signs and symptoms, CC
What symptoms are in the constitutional system?
Chills, diaphoresis, fatigue, malaise, fever, activity change, weight change.
What part of soap includes the physical exam?
Objective
What is palpating used for?
To look for tenderness and organomegally
Wd/wn, NAD, and non toxic appearing are xamples of what part of the PEx?
Constitutional/general appearance
NCAT would be found in which part of PEx?
hENT
When can you document PERRLA?
When light is shined into Pt eyes
When can you document EOMI?
When the patient is tracking the physician
Normal findings in CV include…
rRR, heart sounds normal. Intact distal pulses
What is CVA assoc with and what part of the PEx is this found in?
Kidney stones and nephritis, GI
Normal findings in neuro include
AOx3, SLR normal, DTRs normal
What will the scribe always Check?
Vital signs reviewed, nurses note reviewed.
What is the e/m level based on?
complexity of evaluation and treatment.
What is the e/m level made up of?
history&physical, MDM
Where is the amount of critical care time entered in the chart?
in the MDM section
