Week 1

Question 0

Subjective Data

Answer 0

What the patient tells you. Includes the CC, HPI, PMH, PSH, SH, FH, allergies, meds and immunizations and ROS

Question 1

What does SOAP stand for?

Answer 1

S - subjective
O - objective
A - assessment
P - plan

Question 2

What does CC stand for?

Answer 2

Chief complaint.

It is the reason for the patient’s visit in their own words

Question 3

What does HPI stand for and what does it do?

Answer 3

History of present illness.

• Tells the story (concise story)
• Written in paragraph format-no headings here

Question 4

What does OLDCARTA stand for?

Answer 4

O - onset
L - location
D - duration
C - characteristics
A - aggravating factors
R - relieving factors
T - treatment
A - associated symptoms

Question 5

What is the acronym that helps in writing/ collecting data for the plan?

Answer 5

DMERF

Question 6

In what format is the plan written?

Answer 6

A paragraph format.

Question 7

What does DMERF stands for?

Answer 7

D - diagnostics
M - medications
E - education
R - referrals
F - follow ups

Question 8

Objective Data

Answer 8

The findings resulting from direct observation by the examiner. This is what you see, hear or touch – your physical exam findings and vital signs or labs.

Question 9

Diagnosis

Answer 9

What you conclude from the subjective and objective findings

If diagnosis is not clear, include a differential diagnosis – try to list in order of priority or likelihood.