Subjective Flashcards
There are 4 types of patient/ client notes, what are they?
- Initial evaluation
- Daily note
- Progress or Re-Evaluation
- Discharge
When is the initial evaluation note completed?
Upon the first patient encounter
When is a daily note completed?
After every session with the patient
When is a progress or re-evaluation note completed?
- Periodically
- Progress: 1x per week or change of status
- Re-eval: 1x: per month or change of status
When is a discharge note completed?
When therapy is complete
What falls under the S part of your soap note?
Subjective information (examination)
What falls under the O part of your soap note?
Objective information (examination)
- Observation
- Palpation
- ROM, Strength
- Special Tests
What falls under the A part of your soap note?
Assessment (valuation: S+O)
- Diagnosis
- Prognosis
- Goals
What falls under the P part of your soap note?
Plan
The subjective the the patients _____ communication concerning the chief complaint.
Verbal
Does subjective only come from the patient?
No, it can come from a coach, caregiver, PA, family member, etc
What do you start with when writing your subjective?
- Who
- What happened
- When did it happen
- Where did it happen
- How did it happen
What can you be doing while actively listening to your patient?
- Processing the information
- Observing non-verbal cues
- Direct objective choices
When writing your subjective many use the mnemonic “old charts”, what does this mean?
- Onset: when
- Location: where
- Duration: how long
- CHaracter: description
- Alleviating/ Aggravating factors: better or worse
- Radiation: does it stay in one area or move
- Time: time of day better or worse
- Severity: sharp, dull, aching, pain scale
What is an extremely important piece of your subjective that you cannot miss?
Past medical history
