S in SBAR - Answers Situation: what is happening. chief complaint. conclude with status update
B in SBAR - Answers Background: give details related to main problem, PMH, SH, meds, etc.
A in SBAR - Answers Assessment: interpret situation and background
R in SBAR - Answers Recommendations: plan
Purpose of SBAR - Answers Useful in a variety of situations and enhances interprofessional
collaboration
Inspection - Answers General observation of the patient
Palpation - Answers The use of sense of touch in evaluation of the patient
Percussion - Answers Used to produce sounds, elicit tenderness, or assess reflexes in a patient
Auscultation - Answers Listening for normal and abnormal sounds with a stethoscope
Imaging Diagnostic Tests - Answers X-ray, MRI
Electrophysiology Diagnostic Tests - Answers EKG, EEG
Screening Results Diagnostic Tests - Answers Blood cultures
Risk Calculations Diagnostic Tests - Answers ASCVD risk
NCAT - Answers Normocephalic atraumatic
PERRLA - Answers Pupils equal, round, reactive to light and accommodation
EOMI - Answers Extraocular muscles intact
Imaging Insights - Answers Blood clots, tumors, blood flow, etc.
EEG - Answers Electroencephalogram: measures electrical activity of the brain
RRR - Answers Regular rate and rhythm
Consolidation - Answers Areas of the lung where air should be, but is not
Infiltrate - Answers Dead cell, debris, pus commonly seen with pneumonia
Atelectasis - Answers Partially or fully collapsed lung
Pleural Effusion - Answers Fluid in the space between chest wall and lungs
Aspiration - Answers Inhalation of food particles or stomach contents
, CT Scan - Answers Computed tomography scan. Assesses pulmonary embolism, lung masses,
internal bleeding, edema. May also require IV contrasts
Echo - Answers Echocardiogram. Ultrasound of heart. Info about size, shape, pumping of heart
EKG/ECG - Answers Electrocardiogram. Measures electrical activity of the heart
Cardiac Catheterization - Answers Looks for disease of heart muscle using coronary
angiography (contrast dye) to see movement through arteries
PFT - Answers Pulmonary function test. Measures lung volume using FEV1 and FVC
FEV1 - Answers Forced expiratory volume in 1 second
FVC - Answers Forced vital capacity
EGD - Answers Esophagogastroduodenoscopy. Helps locate GI bleeds
Doppler Ultrasound - Answers Detects blood flow issues, and DVT: deep vein thrombosis
Empiric Coverage - Answers Starting antibiotics before the bacteria causing infection is known
S in Microbial Report - Answers Sensitive: bacteria killed by the antibiotic
R in Microbial Report - Answers Resistant: bacteria is immune to the antibiotic
Purpose of SOAP Notes - Answers Improve patient care and outcomes, enhancing continuity of
care
S in SOAP Notes - Answers Subjective
O in SOAP Notes - Answers Objective
A in SOAP Notes - Answers Assessment
P in SOAP Notes - Answers Plan
Subjective Portion of SOAP Note - Answers CC, HPI, PMH, FH, SH, Meds, Allergies, IMZ, ROS:
PHYSICAL EXAM
Objective Portion of SOAP Note - Answers Vital signs, physical exam, laboratory tests, serum
drug concentrations, diagnostic tests
SOAP note - Answers A structured method for documenting patient assessments and plans.
Evidence - Answers As evidenced by... secondary to.
Goals - Answers Objectives set for patient care, including pharmacologic, nonpharm, and
education and counseling.