General Flashcards
(20 cards)
SOAP
Subjective History (English), Objective findings, Assessments, Plans (Medical language)
Components of History
Initial data, Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Social History (SH), Family History (FH), Review of Systems (ROS)
Initial Data
Name of patient, date, time, MRN (medical record number), DOB, Source of history (patient, spouse, parent), Reliability
Chief complaint
written in patient’s own words, reason for seeking care
OLD CARTS
Onset, Duration, Location, Character, Aggravating, Associated factors, Relieving factors, Temporal factors, Severity (pain scale, effect on ADLs)
Past medical history
current/chronic medical conditions, surgeries, hospitalizations, injuries and illnesses, immunizations, medications (Rx, OTC, herbal), allergies (ask about type of reaction), GYN history (LMP, pap info, age of menarche, menstrual pattern), blood transfusions, health care professionals involved, health maintenance
Case specific PMH
birth history in young children, developmental history, anesthesia history if considering surgery
OB History (Basic)
Ever been pregnant? Outcome of that pregnancy? What type of delivery? Problems with pregnancy, labor, delivery?
Health Maintenance
Children: immunizations, growth, development, vision, hearing
Adolescents: immunizations, STD, pregnancy screening
Young Adults: immunizations, Pap, STD screening
Middle Age adults: immunizations, Pap, mammogram, colonoscopy, screening labs
Elders: immunizations, mammogram, colonoscopy, screening labs, bone density
FMH
Blood relatives, ethnicity, ask about diabetes, heart disease, cancer, high cholesterol, high BP, mental illness, other illnesses
Social History
Habits: tobacco, alcohol, drug use, exercise, sleep, caffeine, diet (what do you like to eat?), living situation, marital status, children, support system, employment, travel, pets/exposure to animals, religious beliefs that might affect healthcare, cultural beliefs, military service, level of ed, hometown, birthplace, significant life events, hobbies
ROS
3-5 Q per system
provides info about overall health of patient (promotes detailed list and care plan)
Use terms patient understands
Go slow and wait for response
Immunizations
Children - annual influenza, COVID19
Adolescents - Tdap, HPV, Menactra, COVID19
Young Adults - Tap, HPV, COVID19
Middle Age Adults - Tdap or Td, COVID19
Elders - Tdap/Td, Shingrix, Pneumococcal, COVID19
5 P’s of Sexual Health
partners, practices, protection from STIs, past history of STIs, prevention of pregnancy (sometimes include pleasure)
ROS Summary
General include + or - findings; elaborate on + findings; document at least 3 items for each system and ask items related to patient’s complaint for NP; need multiple systems to justify level of care..ask about items related to patient’s complaint for established patient
Who can be a historian?
patient, parent, child, neighbor, caretaker
When are open-ended questions most useful
During initial part of the interview
Where does diet belong?
Social History
Menarche
first menstrual cycle
Family medical history should include
parents, grandparents, siblings, children
