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Patient Assessment > SOAP note > Flashcards

SOAP note Flashcards

1
Q

Components of HPI?

A

OLDCARTS

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2
Q

What does OLDCARTS stand for?

A 
Onset
Location
Duration
Character
Alleviating/Aggravating
Radiation
Time
Severity
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3
Q

What is part of Past Medical History?

A

All past medical issues

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4
Q

What is part of Past Surgical History?

A

All past surgical issues

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5
Q

What is part of Social History?

A

Drugs, alcohol, job, travel

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6
Q

What is in ROS General?

A

Weight gain/loss, appetite, fatigue, fever/chills/nightsweats

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7
Q

What is in ROS Skin?

A

Color changes, erythema, eccymosis, pruritis, rash, ulceration, laceration, hair growth

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8
Q

What is in ROS HEENT?

A

HA, eye pain/discharge/redness, vision change, hearing change, ear pain/drain, face pain, sore throat, lymphnodes swollen, neck pain

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9
Q

What is in ROS Cardio?

A

Angina, chest pain, palpitations, dizzy, syncope, dyspnea, orthopnea lower ext edema,

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10
Q

What is in ROS Pulm?

A

Cough, SOB, wheeze, asthma, chest pain

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11
Q

What is in ROS GI?

A

Abdominal pain/swelling, N/V/D/constipating, heartburn/indigestion, jaundice, melena, hematochezia, rectal pain/bleed

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12
Q

What is in ROS GU?

A

Hematuria, dysuria, frequency/urgency urinating, urinary retention/hesitation, discharge, abnormal vag bleed, incontinence,

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13
Q

What is in ROS MSK?

A

Neck/back/join pain? Myalgia? Jointt swell?

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14
Q

What is in ROS Heme/Onc?

A

Easily bleed, easily bruise, anemia, swollen lymph nodes, fever, chlls, weight gain/loss, night sweats

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15
Q

What is in ROS Endo?

A

Fatigue, polyuria, polydipsia, weight gain/loss, hair change, abnormal menstrual cycle

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16
Q

What is in ROS Psych?

A

Anxiety, depression, insomina, memory problems, suicidal thoughts

Patient Assessment (1 decks)

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