Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
4 Cards in this Set
- Front
- Back
|
Describe a well patient encounter
|
A complete physical
- No CC - Really delve into PMH, PSH, meds, allergies, FH, SH, ROS, emphasis on patient as a complete person - A & P focused on preventative medicine 1. Exercise 2. Immunizations 3. Diet 4. Smoking cessation 5. EtOH cut back |
|
|
Describe a problem focused encounter
|
- Pt has CC
- Hx more limited, focus on what could be contributing to the complaint but always be aware that something else may be killing the patient - PE: heart, lungs, spine & area of concern - SOAP note more focused - A & P about problem itself |
|
|
Differentiate between a SOAP note & a H & P.
|
SOAP
subjective (OLD CARTS) objective Assessment Plan H & P Same information that is in SOAP note but much more complete & broken into paragraph form - Same abbreviates - Flow of information - CC, HPI, PMH, PSH, SH, FH, Meds, Allergies, ROS, PE, Labs/radiology, Assessment, Plan |
|
|
When to use SOAP vs H & P?
|
SOAP
- Routine visits in some clinics - Hospital rounds for daily notes with emphasis depending on what the focus is H & P - Done upon hospital admission - Required 1 x a year for all nursing home residents - Some consultants make their notes look like H & Ps, but they concentrate on their area of expertise |
