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15 Cards in this Set
- Front
- Back
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What are the purposes of SOAP notes ?
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Diagnostic reasoning
organization medical record audit evidence |
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What are the four contents of the SOAP note ?
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Subjective
Objective Assessment Plan |
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What content makes up the subjective ?
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Health history
What the patient tells you |
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What content makes up the objective ?
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Physical Exam findings
Results of labs and other diagnostic tests done. |
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What content makes up the Assessment ?
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Medical diagnoses
Differential Diagnoses Health Maintenance/Risk profile |
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What content makes up the planning part ?
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Diagnostic tests to be ordered
therapeutics patient education referrals follow up plan health maintenance plan |
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When would you do a comprehensive health history ?
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Initial patient visit
Hospitalized patient H&P On an established patient who was too sick on their initial visit |
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When would you do an episodic history ?
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Problem focused interview that is done on an established patient
-for a new complaint |
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When is an interval health history appropriate ?
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on an established patient
-chronic condition -follow up to an acute illness |
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What are the EIGHT parts of the Comprehensive Health History ?
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Identifying Data
Chief Complaint History of the Present illness Current health data Past History Family History Personal/Social History Review of Systems |
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Identifying data includes what ?
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Name, DOB, age, gender,ethnicity, education level, occupation, marital status, source of history or referral
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The chief complaint is always written in ?
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the patients words...why did they seek care ?
(always directly quote the patient) |
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What are the seven variables of a symptom ?
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Timing
Location Quality Quantity/Severity Setting Aggravating/Alleviating Factors Associated Symptoms |
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Current Health Data includes ?
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Medications
Allergies Screening Tests Immunizations LMP Birth Control ? |
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Past Medical History includes ?
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Childhood illnesses
Adult illnesses Trauma/Injuries/Disabilities Hospitalizations Surgeries OBGYN |
