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15 Cards in this Set

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