SOAP Note Flashcards
What does SOAP stand for?
S: subjective
O: objective
A: assessment
P: plan of action
What does HPI stand for?
History of Present Illness
What does ROS stand for?
Review of Systems
What is something you should ask every pt (not children)? Hint: most medical professionals forget to ask this but can be helpful to cue in more questions/answers
What is your occupation? Are you retired? Do you have any hobbies?
HPI has an mnemonic, what is it?
NLDOCAT
N= nature of illness/problem L= location, where? D= duration, how long? O= onset, when/how did it start? C= course, has anything changed? A= aggravating factors T= treatment
What does PMH stand for?
Past Medical History
What would you ask a pt to get PMH and past surgical history?
Have you had an previous medical problems? Any tests done, such as MRI, CAT, CT scan, etc? Any hospitalizations or surgeries?
What does NKA stand for?
No Known Allergies
What does ETOH mean?
ethanol or alcohol
What does FDLMP stand for?
First Day of Last Menstrual Period
What type of evidence is a symptom?
subjective evidence, what the pt tells you
What type of evidence is a sign?
objective evidence, what you see/observe from the pt
What does WNWD stand for?
Well Nourished, Well Developed
What does B/L mean?
bilateral
What does RRR stand for?
Regular Rate & Rhythm
Dx Vs. DDx?
Dx is the primary/definitive diagnosis
DDx is a differential diagnosis, which means that the Dr. or whoever is evaluating pt has a few guesses to what the pt has and may need further testing or referral
What does prn mean?
as necessary
What does RTO stand for?
Return To Office
What are the 3 Ps?
polyphagia, polydipsia, and polyurea
What is polyphagia?
excessive eating
What is polydipsia?
excessive drinking
What is polyurea?
excessive urination
