Hx and SOAP Note I - Luke (done, barring additions) Flashcards Preview

PCM I > Hx and SOAP Note I - Luke (done, barring additions) > Flashcards

Flashcards in Hx and SOAP Note I - Luke (done, barring additions) Deck (10)
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1
Q

Why take a history?

A

Relationship with patient, billing, aid in diagnosis, medical/legal protection.

2
Q

What types of patient would require a comprehensive history

A

New patients, hospital admissions, annual physicals, consultations.

3
Q

What types of patients would require a focused physical>

A

New problems, recheck of chronic problems.

4
Q

Components of history

A
Patient Demographics
CC- Chief Complaint
HPI- History of Present Illness
PMH- Past Medical History
Medications
Allergies (must have reaction)
Social History
Family History
ROS- Review of Systems
5
Q

Past medical history components.

A
Current medical diagnosis or Chronic conditions
Previous major illnesses (including childhood)
Surgeries
Injuries
Hospitalizations 
Pregnancy history
Immunizations
Screening tests
6
Q

Why should you ALWAYS review allergies

A

Because I said so, also always pertinent to tests/medications.

7
Q

Components of the plan.

A

Tests, treatment, patient education, follow up.

8
Q

Not documented=

A

NOT DONE

9
Q

Do of SOAP note

A

Document, sign note, CC in patients words.

10
Q

Don’ts of Soap note

A

Falsify info, misplace info, forget if write up patient info.