Exam V: SOAP Notes Flashcards Preview

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Flashcards in Exam V: SOAP Notes Deck (18)
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1

SOAP Note

“Acronym for an organized structure for keeping progress notes in the chart”

Subjective
Objective
Assessment
Plan

Starts with Date and Time in the left upper corner
Required by law on every medical document
Every Note must contain the patient’s name somewhere on the sheet along with medical record number
Electronic record
Printed sticker
Hand written

2

CODIERS

Chronology
Onset
Duration
Intensity
Exacerbation
Remitting
Symptoms associated

3

Chronology

Have you had this before
When did you have it
How many times
What did you do for it
Did you see a physician
What did they do
Did that work well

4

Onset, Duration, and Intensity

Onset
When did this start
What were you doing

Duration
How long does it last
Has it changed

Intensity
How bad is it
1-10 scale

5

Exacerbation and Remission

Exacerbation
What makes it worse

Remission
What makes it better
IF a drug made it better: what drug, how much, how often

6

SMASH FM

Surgical history
Medical history
Allergies
Social history (see next slide)
Hospitalizations
Family history
Medications

7

Social History

FED TACOS

Food (diet)
Exercise
Drugs
Tobacco
Alcohol
Caffeine
Occupation
Sexual history

8

Plan

MOTHRR

Medications
OMM
Tests
Holistic/Humanistic
Referrals
Return

9

Subjective Data

CODIERS SMASH FM FED TACOS
What the patient tells you
You are not responsible for making certain it is absolutely correct
You ARE required to record it as accurately as possible

Chief Complaint= simple, best if in the patient’s own words
History of Present Illness
CODIERS – Paragraph format; chronology all together

Symptoms Associated
Pertinent Positives- "patient states"
Pertinent Negatives- "patient denies"

SMASH FM – Bulleted format

10

Objective Data

Vital Signs, Physical exam, test results
Facts that you have determined
YOU ARE responsible for the veracity
Always record this accurately
NEVER record anything you did not actually check
Outline format to make it easy to read

Physical Examination- bulleted with headings with vitals and general assessment

Then work Head to Toe
HEENT – blah blah blah
Respiratory – yada yada yada
Cardiac – etc. etc. etc.
Abdominal
Musculoskeletal
Neurologic
Genitalia

Test results

11

Assessment

Differential Diagnosis
Primary diagnoses first
You must commit to some kind of primary diagnosis even if it comes out “I think you have”
First choice cannot be “Rule out” or “Doubt”
Second and third may be “Rule out”
Label unlikely diagnosis as “Doubt”
Must have 3 diagnoses related to the CC to break even, a 4th will get you one point added (COMLEX)

Secondary diagnoses next
These do not relate to the CC
Any other diagnosis you intend to address
Hypertension, Diabetes, Bee sting allergy

12

Plan for Primary Dx

MOTHRR
Medications – OTC/prescriptions
OMM – not all cases get OMM; may put “will perform OMM next visit”
Tests – Labs/Imaging
Holistic/Humanistic: rest, heat, elevation, not eating before bed; offering to contact family members
Referrals – may also be left out
Return to office – follow-up, call instructions
ALWAYS have a return plan
Hospital admission counts as “Return”

13

How to End a SOAP Note

Your signature and date directly underneath last line so no one can accidentally write in your section

14

Brief Pre-Op Note

Date/Time:
Patient ID: one sentence describing significant PMhx and procedure

79 y/o CF with h/o htn, dm for lap chole

Brief hx and physical (See complete pre-op H&P)
Meds:
Allergies:
Labs: including results of pregnancy test
CXR:
EKG:

Operative consent: signed
Legible Name and Signature

15

Brief Operative Note

Date/Time:

Surgeon:
Assistant:
Pre-op dx
Post-op dx
Procedure
Anesthesia: type i.e. general via ETT, via mask, spinal, regional, local
Fluids
EBL:
U.O.
Drains/tubes
Post op condition
Legible Name and Signature

Operative Note: dictated by surgeon directly afterward; more in depth than the above

16

Discharge Summary

Date of Admission
Date of Discharge
Admitting diagnosis
Final diagnoses
Consultations
Operations/Procedures
Brief History and Physical
Pertinent Labs
Hospital Course
Disposition
Discharge medications
Discharge instructions

17

CBC Symbol

Right: Platelets
Left: WBC
Up: Hbg = hemoglobin
Down: Hct = hematocrit

18

BMP / SMA7

From left to right:

Na/K
Cl/HCO3
BUN/Creatinine
Glucose