SOAP Note & Presenting a Patient

Question 1

what part of the SOAP note would “somatic dysfunction lumbar” go under

Answer 1

assessment

Question 2

what part of the SOAP note would “L4 E RR SR” go under

Answer 2

objective

Question 3

what part of the SOAP note would “MFR performed to lumbar region. well tolerated w/ decrease in paraspinal muscle tone” go under

Answer 3

plan

Question 4

in SPs, do you have to do active motion, passive motion, or both

Answer 4

pick one: active or passive

Question 5

what neuro exams can you perform in a physical exam

Answer 5

DTRs

muscle strengths

Question 6

what are some examples of vascular exams in the physical exam

Answer 6

• pulses
• cap refill
• edema

Question 7

when documenting in the physical exam, what must you make sure to document

Answer 7

BILATERAL FINDINGS

ex:
Right elbow compared to the left: appear symmetric w/o erythema or swelling.
Passive ROM: equal in flexion and extension; painful on right w/ supination and pronation, left w/o pain. Radial pulses 2/4 b/l

Question 8

how many tart findings must an OSE include to meet guidelines for billing

Answer 8

3 out of the 4

Question 9

how should you document a somatic dysfunction in the assessment portion

Answer 9

by the REGION
ex:
somatic dysfunction upper extremity

Question 10

what must you do before performing OMT

Answer 10

• ask permission
• offer EVERY time
• clearly identify yourself as a student or medical student
• discuss informed consent and patient autonomy

Question 11

how should you present a patient for a problem focused visit

Answer 11

• be brief (5 mins)
• provide enough info to tell audience how you came to your dx
• use chronological order
• must follow SOAP note format
• review historical events that led the pt to make the appt
• identify risk factors/underlying med conditions

Question 12

how much of social and family history do you share when presenting an SP case

Answer 12

only share what is relevant to the diagnosis

you don’t need all the normal findings

Question 13

what needs to be included in the ROS

Answer 13

a minimum of one symptom in two systems NOT covered in the HPI

Question 14

essentials to know before presenting

Answer 14

what your goals are (what the listener expects) and how long you will have to present

Question 15

what should your presentation be focused on

Answer 15

providing evidence, pros and cons, for you definition of the problem
- present only relevant data focused upon the problem list

Question 16

12 guidelines for making a presentation

this is like really long and kind of obvious, but it was highlighted in the document so i feel like it’s important

Answer 16

1. goals (what the listener expects) and time available
2. know the patient
3. focus on problem list/diagnoses
4. present only relevant data
5. use standard format: CC/HPI, PE, diagnostic investigation
6. summarize and invited questions
7. be engaging and interesting
8. use note cards only for reminders of factual data
9. practice and get feedback from colleagues
10. observe other good presentations and emulate those
11. avoid logistic and other problems
12. avoid personalizing and recounting specific conversations