Soap Note Flashcards
1
Q
How do you document PE?
A
- be very specific
- was it b/l or u/l?
- put everything you did, saw, and identified in the room (regardless of outcome)
2
Q
Components of vascular assessment
A
- pulses
- edema
- capillary refill
3
Q
OSE
A
- OSE is an OBJECTIVE FINDING
- Must include three of four tart findings to meet guidelines for billing
- Tenderness (pt comment)
- Asymmetry
- Restrictions in motion
- Subtle glides and functional joints motions NOT the same as orthopedic assessment
- Tissue texture changes
4
Q
What is the minimum to report with OSE?
A
SD and region –> go in assessment
5
Q
Where does FH MI go?
A
assessment
*note I said FH MI (not just FH, which would be a SUBJECTIVE account give by pt)
6
Q
What are the key points of pt hand off?
A
- Brief (generally ~ 5 minutes)
- Provides enough information to tell the audience how you came to your most likely dx
- Must be in chronologic order
- Must follow SOAP note format
- Accurately review the historical events that lead the patient to make the appointment
- Identification of risk factors and/or other underlying medical conditions that might affect the diagnosis
- Generate an assessment and plan
7
Q
What do you start with in objective section?
A
vital signs
