The medical chart, formation of diagnosis, & thinking like a doctor

Question 1

What does S.O.A.P stand for?

Answer 1

S. ubjective (What the patient says)

O. bjective (What the doctor says)

A. ssessment (How we acess the information from the patient)

P. lan (How we detail the disagnosis)

Question 2

What are the 4 parts to the subjective?

Answer 2

1. Chief complaint (CC)
2. HPI (History of present illness)
3. ROS (Review of system(checklist of system from the body))

Question 3

Chief Complaint

Answer 3

Main reason the patient is there & what directly cause them to make the appointment (describes & determines the HPI)

Question 4

HPI

Answer 4

The story & context for the chief complaint (Like when did it start, servitiy, etc)

Question 5

What does a complete HPI contain?

Answer 5

1. Element (description)
2. Onset (when did it start)
3. Timing (Is it constant)
4. Location (where does it hurt)
5. Quality (Feel any pain or sharpness)
6. Severity (How bad is it)
7. Modfifying factors (what makes it better or worse)
8. Associated Sx (Any other sysmptoms)
9. Context (Is there anything else)

Question 6

ROS

Answer 6

The head to checklist of the patients body, includes all symptoms the patient mentioned in the HPI (But no story), & never contradicts the HPI (Always matches it)

Question 7

HPI is the place for imformation about the __________

Answer 7

The chief complaint (CC)

Question 8

The ROS sis the place for information about the ___________ & ___________

Answer 8

The chief complaint & anything else

Question 9

Auscultation

Answer 9

Listening usually with stethoscope

Question 10

Palpation

Answer 10

The act of pressing on the area of the body

Question 11

The physical exam is documented into a list of _____________

Answer 11

Specific body parts