Soap Note Lecture

Front 1

Demographic data

Back 1

name, date, time, age, gender
race, occupation, and referral source (where the information is coming from.

Front 2

Subject data includes

Back 2

chief complaint, HPI, PMH, FM, SH, and ROS

Front 3

Problem or Focused History

Back 3

taken whena problem is acute so that only the need of the moment is given full attention

Front 4

Interim History

Back 4

Designed to chronicle events that have occured since your last meeting, nature of problem at the moment

Front 5

OLDCARTS

Back 5

onset, location, characteristics, alleviating or aggregates factors, radiation, timing, serverity

Front 6

when completing the PMH the following need to be explored.

Back 6

General health, Childhood illness, major adult illnesses, immunizations, surgery, serious injuries and resulting in disability, past medications, allergies, transfusions, screening test, and emotional status

Front 7

personal and social history includes

Back 7

personal status, habits, sexual history, home conditions, occuption, environment, military record, religious preference, access to care

Front 8

ROS needs to explore the following

Back 8

General constitutional symptoms, SHN, HEENT, lymph, Chest lungs (heart, blood vessels, peripheral vascular, hematologic, breat female, GI GU, diet, endocrine, MS, Neuro, Psyc

Front 9

What consist of general constitiutional symptoms

Back 9

fever, chills, malaise, Fatigability, night sweats, sleep pattern, weight (change)

Front 10

When conducting a ROS, how should the information be presented

Back 10

General Constitutional symptoms, SHN, HEENT, Lymph, Respiratory, Cardiovascular, Abdomen (GU, Breast (female only) GI, MS, Neuro, Hematological, Endocrine, Psychiatric

Front 11

During the ROS of the SHN what general questions should always be ruled out?

Back 11

Rash, itching, and eruptions
Pigmentation changes, sweating, and abnormal hair growth.

Front 12

During the head and neck of ROS what general questions should always be asked?

Back 12

headache, dizziness, syncope, head injury, loss of consciousness

Front 13

During an eye exam the following symptoms should be questions to ensure the patient hasn't experience them?

Back 13

acuity, blurring, diplopia, photophobia, pain, date of last exam, vision changes, glaucoma, eye medications, and trauma

Front 14

During a nose exam the following symptoms should be questions to ensure the patient hasn't experience them?

Back 14

sense of smell, colds, obstruction, epitaxis, postnasal drainage, sinus pain

Front 15

During throat and mouth exam the following symptoms should be questioned?

Back 15

Hoarseness or change in voice, sore throat, bleeding gums, tooth abscesses or extraction, taste changes and date of last dental exam

Front 16

During the lymph node exam the following symptoms should be questioned?

Back 16

enlargement, tenderness, or suppuration

Front 17

During chest and lung exam the following symptoms should be questioned?

Back 17

pain dyspnea cyanosis, wheezing, cough, sputum, hemoptysis, night sweats, exposure to TB, last chest xray

Front 18

During the breast exam the following symptoms should be questioned?

Back 18

development, pain, tenderness, discharge, lumps, galactorrhea, mammograms, self awarness, and self examination

Front 19

During heart and blood vessels exam the following symptoms should be questioned?

Back 19

chest pain, palpations, dyspnea, orthopnea, edema, claudation, HTN, MI, exercise tolerance, date of last EKG, and other testing

Front 20

During the peripheral vascular exam the following symptoms should be questioned?

Back 20

claudation (limping) tendency to brisue or bleed, thrombophlebitis, thromboses,

Front 21

During hematologic exam the following symptoms should be questioned?

Back 21

anemia, blood cell abnormalities, past transfusions

Front 22

During GI exams the following symptoms should be questioned?

Back 22

appetite, digestion, food tolarance, dysphagia, heartburn, N&V, stools, jaundice, image studies

Front 23

During diet exams the following symptoms should be questioned?

Back 23

appetite, likes, diet restrictions, vitamins and other supplements, caffeine, dietary recall 24hrs

Front 24

During endocrine exams the following symptoms should be questioned?

Back 24

thriod enlargement or tenderness, heat and cold tolerance, weight changes, polydipsia, diabetes, polyuria, changes in facial hair, increased hat or glove size, skin striae

Front 25

During GU exam the following symptoms should be questioned?

Back 25

STD, dysuria, pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone

Front 26

During MS exams the following symptoms should be questioned?

Back 26

joint stiffness, pain , restrictions of motion, swelling, redness, heat, bony deformity

Front 27

During neuro exams the following symptoms should be questioned?

Back 27

synope, seizures, weakness or paralysis, abnormal sensations, tremors, loss or memory

Front 28

During psychiatric exams the following symptoms should be questioned?

Back 28

depression, mood changes, difficulty concentrating, nervousness, tension, suicial thoughts, irritability, and sleep disturbances

Front 29

Concluding history quesitons

Back 29

Is there anything else that you can think would be important for me to know? What problem concerns you most? What do you think is the matter with you? What worries you the most about how you are feeling?

Front 30

After you complete the subjective what then?

Back 30

Physical exam
VS, Head to toe assessment, diagnostic test (labs and results), diagnosis X 3. then a plan to treat the problem along with the education to the patient.