History and SOAP Note I Flashcards
(29 cards)
why take a history
develop relationship with patient
obtain patient info for diagnosis
medical/legal protection
billing
format vs process?
format is organized verbal and written structure of content
process is conversational in method and requires good communication/interpersonal skills
comprehensive history
detailed
for new patients, hospital admission patients, consultations, annual physicals**
problem focused history
shorter and specific
for new problems or recheck of chronic problem
whats on a comprehensive history?
patient demographics CC HPI PMH Meds Allergies Soc Hx Fam Hx ROS
patient demographics?
todays date and time
name
date of birth/age
gender
chief complaint
in patients own words
HPI
in paragraph format**
remaining history is outline format
PMH
current diagnosis chronic condition previous illnesses surgeries injuries hospitalizations pregnancy history immunizations screening tests
include dates**
medications
prescriptions
OTCs
Supplements
include dose and frequency**
allergies
meds, enviro, food
**always include reaction
social history
important is substance use:
- tobacco
- alcohol
- recreational
- caffeine
family Hx
parents, grandparents, siblings, children
review of systems
general HEENT cardiac respiratory GI GU MSK Neuro Psych Vascular Lymphatic/Hematologic/Immune Endo Repro Breast Skin
problem focused?
chief complaint HPI always review allergies and meds pertinent past medical, social, family, ROS focused physical exam assessment/diagnosis plan/treat/diagnostics
always review what on problem focused?
allergies and meds
SOAP?
subjective, objective, assessment, plan
subjective
provided by patient, historical info
objective
provided by examiner
physical observations/exams and other data
assessment
possible dx/DDx and other items to be addresed
plan
how will you investigate diagnoses and treat patient
symptoms?
subjective
-what the patient tells you
signs?
objective
-what the doctor sees or feels on physical exam
subjective includes?
CC, HPI, PMH, Meds, Allergies, Social Hx, Fam Hx, ROS
