SOAP Note Flashcards
1
Q
List the four major components of the SOAP Note.
A
- S – subjective
- O – objective
- A – assessment
- P – plan
2
Q
What are things that fall under S?
A
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Medical History (PMH)
- Past Surgical History
- Family History
- Social History
- Allergies
- Adverse effects
- Medication List
- Immunization History
- Home monitoring
3
Q
What are things that fall under O?
A
- Vital Signs
- Physical Exam
- Pertinent Laboratories
- Diagnostic tests
- Calculations: C-G, IBW, ABW
- Current medications
4
Q
What are things that fall under A?
A
- Identify problems; prioritize and be specific
- Reasoning behind your plan; incorporate evidence-based plans
- Provide goals of therapy; include prospective drug review
5
Q
What are the types of patient assessment?
A
- System-based assessment -> Organize assessment by organ system
- Problem-based assessment
6
Q
When can you use System-based assessment?
A
Can be used for complex, critically-ill patients , where an array of issues may impact other organ systems.
7
Q
When can you use Problem-based assessment?
A
Can be used when a particular disease requires multiple facets of management
