SOAP Basics Flashcards
SOAP
subjective, objective, assessment, plan
subjective
based on the patient’s feelings
HPI and ROS
objective
factual information from provider (PE)
history of present illness
story of patient’s chief complaint (CC)
paragraph form
HPI
review of systems
head-to-toe checklist of patient’s symptoms
ROS
intermittent
comes and goes
type of timing
waxing and waning
always present but changing in intensity
type of timing
modifying factor
something that makes a symptom better or worse
exacerbate
to make worse
type of modifying factor
attestation
the scribe and providers sign off that the chart was prepared by a scribe and approved by provider
chief complaint
main reason for visit
CC
required
elements of HPI
onset, timing, location, quality, severity, modifying factors, associated symptoms, context
O T L Q S M AS C
elements of HPI
onset, timing, location, quality, severity, modifying factors, associated symptoms, context
onset
when did the complaint begin
timing
is the issue constant, intermittent, or waxing and waning
location
where is the issue
quality
how does the issue feel (sharp, dull, aching, cramping)
severity
how bad does the issue feel (scale 0-10)
associated symptoms
other systems that accompany the complaint
associated Sx
context
anything else that may be important or related to the CC (prior symptoms, prior evaluation)
types of HPI structures
single complaint (most common), multiple complaint, chronologic
single complaint
1-2 CC
most common structure of HPI
multiple complaint
when CC are multiples and not related
each CC gets it’s own paragraph
structure of HPI
chronologic
multiple comorbidities with significant workup in the past
pt coming for a follow-up
structure of HPI
3 approaches to ROS
physician-led, nurse-led, patient questionnaire
body systems
- general/constitutional
- eyes
- ENT
- neck
- cardiovascular
- pulmonary/respiratory
- abdominal
- musculoskeletal
- neurological/psychiatric
