SOAP NOTES AND CULTURAL
COMPETENCE FINAL PAPER SOLVED
QUESTIONS WITH FULL PRACTICE
SOLUTION
●● S
Answer: Anything the patient or family tell you
Chief Complaint & Duration
HPI- include SLIDTA
History-PMH, PSH, Medications, Allergies
Chief complaint:
HPI:
Significant PMH/PSH:
Allergies:
Medications:
Social: who do you live with, do you have significant other?
Smoking:
ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize
CAGE)
Do you drink alcohol? How much?
Living environment: (Ask If there is an area of concern)
- do you feel safe, are you afraid in your own home?
,-ab pain we don't care about cataract surgery, not relevant
●● CAGE
Answer: Cutting down, annoyance when asked about drinking, Guilt do
you feel guilty about it, Eye opener - to get you going in the morning
-if response is 2/4 needs further evaluation
●● Chief Complaint
Answer: Limited to one complaint, most pressing
Brief- as few words as possible
Duration always included
Example: Sore throat for 2 days
-why they are here
ex: fevers , chills, nausea (associated sx) but PAIN is the main thing,
most important
-anyone who presents with painful urination always question STD/STI,
ask about discharge, sexual activity, check back for CVA tenderness
ex: constipation, ear pain, otitis media, pharyngitis
-to determine the reason patient seeks care
-important to consider using the patient's terminology
-provides "title" for the encounter
-what brings you to the office? why did the symptom bring you to the
office?
,-describe it like you would to a relative or neighbor
●● History of Present Illness
Answer: -Follows the Chief Complaint
-Always starts with: "This is a (age/race/sex)
-Narrative statement
-You ask the appropriate questions and record the patient's responses.
-You guide the patient to answer your questions.
-Include SLIDTA
-Difference between SOAP and H&P: associated symptoms go in body
of HPI
-This is a 52 year old African American male who presents today with....
-If fever - always write temp max
-Patients' positive response to ROS is recorded as reports..........
Patients' negative response to ROS is recorded as denies.......
Omit: "he" "she" "patient" "patient states"
-Gather information in an orderly fashion to come to a diagnosis
-90% of the time the diagnosis is made by the end of the HPI (assuming
that you have asked the correct questions)
-Learning how to ask the right questions is key
-Don't write "here" or "with complaints"
-"Reports not sexually active." Easy way out for course
, -In the body of this in a soap note: may include medications, past
medical, past surgical and social if relevant to chief complaint - or can
write below this
-Include reverent review of systems
-Must write year when meds were started - must include, if they don't
know write "unknown start date"
-Drug, food, seasonal and environmental allergies - latex
-Smoking - Do you smoke? Have you ever smoked cigarettes? Denies a
smoking history.
-Alcohol - Do you drink? How much do you drink? How often do you
drink?
-Drugs - Did you ever or do you ever use recreational drugs? Crack
cocaine, heroin, marijuana?
Ex: Abdominal Pain: duration, location, type, severity, SLIDTA, fever?
n/v? weight loss? - Denies n/v, constipation, diarrhea, melana etc.
Reports bright red blood in stool x 1 episode 2 days ago.
-to provide a thorough description of the chief complaint and current
problem: suggested format P Q R S T
●● SLIDTA
Answer: Severity - rating the pain, disability "patient no longer able to
bathe himself, no longer able to climb 5 steps" or 2/10
Location - anatomical, specific,
COMPETENCE FINAL PAPER SOLVED
QUESTIONS WITH FULL PRACTICE
SOLUTION
●● S
Answer: Anything the patient or family tell you
Chief Complaint & Duration
HPI- include SLIDTA
History-PMH, PSH, Medications, Allergies
Chief complaint:
HPI:
Significant PMH/PSH:
Allergies:
Medications:
Social: who do you live with, do you have significant other?
Smoking:
ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize
CAGE)
Do you drink alcohol? How much?
Living environment: (Ask If there is an area of concern)
- do you feel safe, are you afraid in your own home?
,-ab pain we don't care about cataract surgery, not relevant
●● CAGE
Answer: Cutting down, annoyance when asked about drinking, Guilt do
you feel guilty about it, Eye opener - to get you going in the morning
-if response is 2/4 needs further evaluation
●● Chief Complaint
Answer: Limited to one complaint, most pressing
Brief- as few words as possible
Duration always included
Example: Sore throat for 2 days
-why they are here
ex: fevers , chills, nausea (associated sx) but PAIN is the main thing,
most important
-anyone who presents with painful urination always question STD/STI,
ask about discharge, sexual activity, check back for CVA tenderness
ex: constipation, ear pain, otitis media, pharyngitis
-to determine the reason patient seeks care
-important to consider using the patient's terminology
-provides "title" for the encounter
-what brings you to the office? why did the symptom bring you to the
office?
,-describe it like you would to a relative or neighbor
●● History of Present Illness
Answer: -Follows the Chief Complaint
-Always starts with: "This is a (age/race/sex)
-Narrative statement
-You ask the appropriate questions and record the patient's responses.
-You guide the patient to answer your questions.
-Include SLIDTA
-Difference between SOAP and H&P: associated symptoms go in body
of HPI
-This is a 52 year old African American male who presents today with....
-If fever - always write temp max
-Patients' positive response to ROS is recorded as reports..........
Patients' negative response to ROS is recorded as denies.......
Omit: "he" "she" "patient" "patient states"
-Gather information in an orderly fashion to come to a diagnosis
-90% of the time the diagnosis is made by the end of the HPI (assuming
that you have asked the correct questions)
-Learning how to ask the right questions is key
-Don't write "here" or "with complaints"
-"Reports not sexually active." Easy way out for course
, -In the body of this in a soap note: may include medications, past
medical, past surgical and social if relevant to chief complaint - or can
write below this
-Include reverent review of systems
-Must write year when meds were started - must include, if they don't
know write "unknown start date"
-Drug, food, seasonal and environmental allergies - latex
-Smoking - Do you smoke? Have you ever smoked cigarettes? Denies a
smoking history.
-Alcohol - Do you drink? How much do you drink? How often do you
drink?
-Drugs - Did you ever or do you ever use recreational drugs? Crack
cocaine, heroin, marijuana?
Ex: Abdominal Pain: duration, location, type, severity, SLIDTA, fever?
n/v? weight loss? - Denies n/v, constipation, diarrhea, melana etc.
Reports bright red blood in stool x 1 episode 2 days ago.
-to provide a thorough description of the chief complaint and current
problem: suggested format P Q R S T
●● SLIDTA
Answer: Severity - rating the pain, disability "patient no longer able to
bathe himself, no longer able to climb 5 steps" or 2/10
Location - anatomical, specific,
