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
Why is it important not to miss PMH?
It may help you find a RED FLAG!
What is a part of a PHM?
- Previous injuries
- Previous surgeries
- Previous incidents like CC
- Allergies
- Alcohol
- Family history
- Social history
- Work
- School
If you do not have enough subjective information what do you do?
Ask more questions!
What do you not chase?
The pain/ symptom!
Is subjective information always accurate?
No
Does subjective information always reflect what is happening objectively?
No
