SOAP Note

Question 1

ROS should include a mininum of ___ symptom in ___ systems

Answer 1

1 symptom in 2 systems

Question 2

What goes under assessment?

Answer 2

1. Restate CC with at least 3 DDx.
2. Global assessment
   
   1. • Second assessment in this order of preference: PMHx > SD not related to CC > Social history problem (smoker, etOh) > familty hx of ________
   2. • Third assessment in that same order

• SOB: COPD, asthma, stable angina
• Mild depression
• SD thorax

Question 3

What goes under plan?

Answer 3

• 1. “Performed ___\__(name of technique)_______ (location)”
• 2. Meds: changes or new meds
• 3. Diagnostics (labs, EKG, radiology)
     * Labs today: CMP, CBC, etc
     * EKG today
• 4. Self-care instruction (stop smoking, no weight breaing)
• 5. Follow up and time frame

Question 4

do we list EVERTHING we did for PE?

Answer 4

YES, no matter the outcome

Question 5

OSE is an _____ finding. What must it include?

Answer 5

Objective

3/4 TART findings

Question 6

Subtle glides and functional joint motions are ________ same as orthopedic assessment

Answer 6

NOT the same

Question 7

How to document SD of the thorax in assessment?

Answer 7

SD thorax

Question 8

How do I know if a case of a OMT case or not?

Answer 8

OMT is a medical procedure and should be offred everyt itme

Question 9

How do you orally present patient?

Does it have to be in chonological order? Does it have to ofllow SOAP note format?

Answer 9

Make it brief (5 minutes) and give enough info to tell audience how you came to conclusion.

Yes and yes

Question 10

when orally presenting the patient, what info must you include?

Answer 10

• 1. historal events that led pt to make apt
• 2. Risk factors, underlying medical conditions that may affect Dx.
• 3. Assessment and plan

Question 11

When presenting the patient, how in detail should you be for PMH/PSH and SH/FH?

Answer 11

PMH/PSH: only if important to reason for visit

SH/FH: if relavant to diagnosis

Question 12

When presenting patient, what should you always include in PE?

Answer 12

• VS, general description, CV, lungs
• Findings that support your 1st differential (working dx or primary dx)

Question 13

when documenting a R elbow pain findings, what do we always include?

Answer 13

1. Bilateral

2. grading scales

3. Inspection

4. Palpation

5. Vascular and neuro assessment

Question 14

In assessment, when we have a SD we name the ____

Answer 14

region

Question 15

FH MI

goes where?

Answer 15

assessment

Question 16

what goes under “assessment #2 and #3”

Answer 16

anything that we have ID’d is new to the patient ORRRR problem or risk factors that are important to the long-term care of the patient

SD lumbar

FH MI

Question 17

when offering OMT, it is important to do what?

Answer 17

introduce yourself as a student

Question 18

when presenting the patient, should we go in great detail?

Answer 18

no; only talk about pertinent positives and pertinent negatives

Question 19

can you use notecards for presenting the pt

Answer 19

only for reminders of factual data

Question 20

entire presentation should be focused on what?

Answer 20

providing evidence

pros and cons

for your deficnition of the problem