Week 1 - SOAP

Question 1

History

Answer 1

Subjective

Question 2

Physical

Answer 2

Objective

Question 3

Diagnosis

Answer 3

Assessment

Question 4

Treatment

Answer 4

Plan

Question 5

What 5 things do we put in a SOAP note that is not part of CHAMPS For Real?

Answer 5

1. Date and Time of visit
2. Identifying data
3. Immunizations
4. Vitals
5. Exam of specific body areas/systems

Question 6

Is CHAMPS For Real and the other 3 things subjective or objective?

Answer 6

Subjective

Question 7

What 3 things are in the Objective portion?

Answer 7

1. Vitals
2. Exam of specific body areas/systems
3. Test results

Question 8

2 things with CC

Answer 8

1. Problem

2. Duration

Question 9

4 things with Allergies

Answer 9

1. Food
2. Drugs
3. Environment
4. Reaction

Question 10

5 things with Medications

Answer 10

1. Medication
2. Milligrams (how much?)
3. Pills (how many, 1 tab, 1/2 tab?)
4. Route
5. Schedule

Question 11

4 things with PMH

Answer 11

1. Significant problems
2. When diagnosed
3. Treatment
4. Status

Question 12

4 things with PSH

Answer 12

1. Surgeries or injuries
2. When
3. Why
4. Status

Question 13

2 things with Immunizations

Answer 13

1. What

2. When

Question 14

4 things with Alcohol, Smoking, and Drugs

Answer 14

1. What do they drink/use
2. How much do they drink/use
3. How long have they been drinking/using
4. If not, when did you stop?

Question 15

4 things with FH

Answer 15

1. 1st degree relatives
2. Alive or dead
3. Ages
4. Problems

Question 16

6 things with Vitals

Answer 16

1. BMI
2. Pulse
3. BP
4. RR
5. Temp
6. O2 Sat

Question 17

3 things we put in Assessment

Answer 17

1. Pertinent positive and negatives for today’s visit
2. Differential and lead diagnosis w/ BRIEF supporting defense or lack thereof
3. “Other” problem list

Question 18

What 4 thins do we put in Plan

Answer 18

1. Patient education
2. Additional diagnostics (if any)
3. Therapy recommendations
4. Follow-up plans

Question 19

Does temp fluctuate? What may it be in the early morning or late evening?

Answer 19

Yes; possibly 96.4 in morning, 99.1 in evening

Question 20

What 2 things are higher in temp than oral? By how much?

Answer 20

1. Rectal (0.7-0.9)

2. Tympanic (0.8-1.4)

Question 21

What is lower than oral temp? By how much?

Answer 21

Axillary (1 degree)

Question 22

How long does it take to get axillary temps? How is its accuracy considered?

Answer 22

5-10 minutes; less accurate

Question 23

What is the chief cause of decreased temp?

Answer 23

Exposure to cold

Question 24

What 3 things could cause decreased heat production?

Answer 24

1. Reduced movement as in paralysis
2. Starvation
3. Hypothyroidism

Question 25

What could cause increased heat loss?

Answer 25

Interference with vasoconstriction