Soap Notes Cultural Competency Expert Study Guide - Verified A-Grade Answers

SOAP NOTES CULTURAL COMPETENCY EXPERT STUDY GUIDE - Verified A-Grade Answers Focused Exam - answer - -Patient encounter where the "focus" is on the patient's chief complaint -are documented in a SOAP NOTE -SOAP notes are not complete History & Physicals -perform this -problem oriented -only ask questions related to chief complaint -what brings patient to this visit 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, Influencing Factors - what makes it better? What makes it worse? Reports.... Denies.... (Don't write the word "patient" or