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
