SOAP Notes and Cultural Competency
Focused Exam
-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
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
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CAGE
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
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
-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
PQRST
SLIDTA
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 "any")
Duration (write it again in the HPI even though it's in Chief Complaint)
Type - sharp, stabbing, dull, aching
Associated symptoms - review of systems, should be related to or about the Chief complaint
-Proceed to more specific questions to help you rule in and rule out your differentials
PQRST
Precipitating and palliative factors - to identify factors that make the symptom worse and/or
better; any previous self-treatment or prescribed treatment; and response
Quality and quantity descriptors - to identify patient's rating of symptoms (pain on a 1-10 scale)
and descriptors (numbness, burning, stabbing)
Region and radiation - to identify the exact location of the symptom and any area of radiation
Focused Exam
-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
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
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:01
,/
0:15
Full screen
Brainpower
Read More
CAGE
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
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
-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
PQRST
SLIDTA
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 "any")
Duration (write it again in the HPI even though it's in Chief Complaint)
Type - sharp, stabbing, dull, aching
Associated symptoms - review of systems, should be related to or about the Chief complaint
-Proceed to more specific questions to help you rule in and rule out your differentials
PQRST
Precipitating and palliative factors - to identify factors that make the symptom worse and/or
better; any previous self-treatment or prescribed treatment; and response
Quality and quantity descriptors - to identify patient's rating of symptoms (pain on a 1-10 scale)
and descriptors (numbness, burning, stabbing)
Region and radiation - to identify the exact location of the symptom and any area of radiation
