SOAP Note QUESTIONSWITH DETAILED
VERIFIED ANSWERS (100% solved
, What is an H&P - ANSWER•Detailed
•Complete history and exam
•1st outpatient encounter
•Admission to hospital
•Psych intake
What is a SOAP note - ANSWER•Based on CC
•Episodic-
-Outpt sick visit: Sore throat/rash; Not the first time you are seeing pt
-ER visit
•Chronic-
-maintenance of chronic (DM, HTN)
What does SOAP stand for - ANSWER-subjective
-objective
-assessment
-plan
chief complaint (subjective) - ANSWER•Should be in the patient's own words
•Use quotes
-Ex: "I have a cough" x 3 days
•More than one CC?
-Use only 1, and the other complaint use as an associated symptom
-Ex: pt reports "I have a cough and a fever" x 3 days
•CC: "I have a cough" x 3 days and in HPI fever will be an associated symptom
HPI (subjective) - ANSWER•Keep in mind:
-Fully PQRST one symptom before going onto the next
•Don't forget to ask if pt has had symptoms before
-If patient reports fever, MUST document whether or not they took their temp
-Risk factors/social history should be included in HPI if relevant to the CC
•SMOKING
pertinent negs (subjective) - ANSWER•As a general rule, should include system,
system above and system below the system involved in the chief complaint
PMH (subjective) - ANSWER•What should I include??
-Adult Illnesses
-Hospitalizations/Surgeries (relevance?)
-Medications
•ROUTE, DOSE, FREQUENCY
-Allergies
•NKDA, NKFA, NKEA
VERIFIED ANSWERS (100% solved
, What is an H&P - ANSWER•Detailed
•Complete history and exam
•1st outpatient encounter
•Admission to hospital
•Psych intake
What is a SOAP note - ANSWER•Based on CC
•Episodic-
-Outpt sick visit: Sore throat/rash; Not the first time you are seeing pt
-ER visit
•Chronic-
-maintenance of chronic (DM, HTN)
What does SOAP stand for - ANSWER-subjective
-objective
-assessment
-plan
chief complaint (subjective) - ANSWER•Should be in the patient's own words
•Use quotes
-Ex: "I have a cough" x 3 days
•More than one CC?
-Use only 1, and the other complaint use as an associated symptom
-Ex: pt reports "I have a cough and a fever" x 3 days
•CC: "I have a cough" x 3 days and in HPI fever will be an associated symptom
HPI (subjective) - ANSWER•Keep in mind:
-Fully PQRST one symptom before going onto the next
•Don't forget to ask if pt has had symptoms before
-If patient reports fever, MUST document whether or not they took their temp
-Risk factors/social history should be included in HPI if relevant to the CC
•SMOKING
pertinent negs (subjective) - ANSWER•As a general rule, should include system,
system above and system below the system involved in the chief complaint
PMH (subjective) - ANSWER•What should I include??
-Adult Illnesses
-Hospitalizations/Surgeries (relevance?)
-Medications
•ROUTE, DOSE, FREQUENCY
-Allergies
•NKDA, NKFA, NKEA
