SOAP Note Refresher and Presenting the Patient

Question 1

What is the minimum that should be included in the ROS of a SOAP note?

Answer 1

Review of Systems: This should include a minimum of one symptoms in two systems not covered in the HPI. For more explanation, please review Bates’ 12th ed., pp. 11- 13.

Question 2

What are all the characteristics included in a PMHx of a SOAP note?

Answer 2

Past Medical History (PMH): Other active problems and can include things the patient has not told a doctor about (for example, acid reflux). Prior hospitalizations for medical problems should be listed here. These are also problems a patient has had in the past, for example childhood asthma, that are now resolved.

Question 3

What kind of procedures are included in the PSHx?

Answer 3

Past Surgical History (PSH): include surgeries and outpatient procedures such as colonoscopies, EGDs, coronary stent placement, etc.

Question 4

What are the components of the social history?

Answer 4

Social History (SH): Must include tobacco (quantity and duration), ETOH (quantity and frequency), recreational drugs (quantity, frequency, and route), occupation, relationship status, and if relevant sexual history, diet, exercise, spirituality, etc.

Question 5

What must be documented in regards to tobacco use?

Answer 5

Social History (SH): Must include tobacco (quantity and duration), ETOH (quantity and frequency), recreational drugs (quantity, frequency, and route), occupation, relationship status, and if relevant sexual history, diet, exercise, spirituality, etc.

Question 6

What must be documented in regards to alcohol use?

Answer 6

Social History (SH): Must include tobacco (quantity and duration), ETOH (quantity and frequency), recreational drugs (quantity, frequency, and route), occupation, relationship status, and if relevant sexual history, diet, exercise, spirituality, etc.

Question 7

What must be documented in regards to recreational drug use?

Answer 7

Social History (SH): Must include tobacco (quantity and duration), ETOH (quantity and frequency), recreational drugs (quantity, frequency, and route), occupation, relationship status, and if relevant sexual history, diet, exercise, spirituality, etc.

Question 8

What are the minimum components included in a family history?

Answer 8

Family History (FH): Minimum of first degree relatives (parents, siblings, children). Or if adopted, state that.

Question 9

What are the parts of the objective portion that must be documented before the problem-focused exam points?

Answer 9

Vital Signs (VS) BP, Pulse, Respiration rate and Temp (height and weight not required)

General: Alert, well kept, appears stated age, no distress.

Heart:

Lungs:

Osteopathic Structural Exam (OSE): T-spine recommended BUT can be directed to the exam related to chief complaint. (if you plan to do suboccipital release, please assess the C-spine and OA/AA and include documentation of your findings).

Question 10

How many exams should be included in the problem-focused exam points?

Answer 10

Problem-focused exam points – there is no set amount of exams you should do, as each problem has a different number of exams a physician SHOULD do. You should do as many as you think are necessary to develop a reasonable differential diagnosis and plan. Documentation should include appropriate grading scales. Positive as well as negative findings need to be included.

Question 11

What is included in the first line or “1.” of an assessment?

Answer 11

Restatement of the chief complaint followed by 3 differential diagnoses (_______: Diff Dx= _most likely, ___________, least likely)

Question 12

What is included in the second line or “2.” of an assessment?

Answer 12

Anything you identified that is NEW for the patient
like the SD you found

Second assessment in this order of preference: PMHx > somatic dysfunction not related to chief complaint > social history problem (smoker, excessive alcohol use, etc.) > family history of ______.

Question 13

What is included in the third line or “3.” of an assessment?

Answer 13

Third assessment in this order of preference: PMHx > somatic dysfunction not related to chief complaint > social history problem (smoker, excessive alcohol use, etc.) > family history of __________.

Question 14

What must be at the top of the plan portion of the SOAP note?

Answer 14

PLAN:
Consider the following, use as many as are indicated:

OMT performed (must start with the word “performed,” and name the technique and location). It should also relate to the documented OSE finding.
If you plan to do OMT at future visit, state “Next visit”
Medications changes or new medications for treatment
Diagnostics (lab, EKG, radiology)—be as specific as possible
Self-care instructions (quit smoking, no weight bearing, etc.)
Follow-up: should include time-frame

Question 15

What needs to always be included in PE reporting?

Answer 15

-ALWAYS COMPARE BILATERALLY
-INSPECTION
-PALPATION
-RANGE OF MOTION
either active or passive
-VASCULAR ASSESSMENT
pulses, edema, cap refill
-NEURO ASSESSMENT
DTRs, strength, sensation

Question 16

What is the difference between OSE and the assessment portion pertaining to OMM?

Answer 16

OSE is an OBJECTIVE FINDING
Must include three of four tart to meet guidelines for billing
Goes in the objective

Name the region of the SD in the ASSESSMENT
Example:
Assessement: SD Thorax

Question 17

What are the acceptable uses of alcohol for both men and women?

Answer 17

for a man- 2 drinks per day or 14 drinks per week

for a woman- 1 drink per day or 7 drinks per week

Question 18

Identify components of the past medical history (PMH), social history (SH) and family history (FH) that can also be utilized within the Assessment portion of a
SOAP note.

Answer 18

deleterious FH like a MI
current tobacco use/addiction/abuse
excessive EtOH use

Question 19

When should I offer OMT to a patient?

Answer 19

EVERY SINGLE TIME. EVERY SINGLE TIME

Question 20

Outline elements of an appropriate oral presentation pertaining to a patient chief
complaint, history, and physical examination with integration of assessment and
plan as indicated.

Answer 20

Brief (generally ~ 5 minutes for outpatient setting)

Provides enough information to tell the audience how you came to your conclusion (most likely diagnosis)

Must be in chronologic order

Must follow SOAP note format

Accurately review the historical events that lead the patient to make the appointment

Identification of risk factors and/or other underlying medical conditions that might affect the diagnosis

Generate an assessment and plan (you must commit)

Question 21

Identify a reasonable, time-limited format in the oral presentation of a patient
case that provides concise and succinct flow in professional communication.

Answer 21

Reason for visit: includes patient demographic (age, gender, race)
HPI:
ROS: pertinent + and –
PMH & PSH: if pertinent to the reason for the visit
Current medications & allergies
SH & FH: if relevant to the diagnosis
PE: always include VS, Gen’l description, CV, Lungs and findings that support your first differential (working diagnosis or primary diagnosis)
A: CC followed by 3 DDX
Global assessment 2, 3
P: be specific to address the primary diagnosis

Question 22

What is the most important thing to remember about documenting PE findings?

Answer 22

DOCUMENT everything you did regardless of outcome