Exam 1 Topic Areas
1) Soap notes documentation. Understanding the
components of Soap note sections. CC, HPI, PMH, FH,
SH, ROS, PE. What information is documented in
these sections.
a. CC: chief complaint -> presenting problem ->
what the patient states. May be stated verbatim in
quotation marks. Always include the duration of
the chief complaint
b. HPI: history of present illness -> detailed
description of sxs that may be r/t the cc ->
OLDCARTS
i. ONSET: when did the problem or sxs first
start; manner of the onset (sudden or
gradual)
ii. LOCATION: exact location (localized,
generalized, radiation patterns)
iii. DURATION: length of problem/episode; if
intermittent, duration of each episode
iv. CHARACTER: nature of pain (stabbing,
burning, sharp, dull, gnawing)
v. AGGRAVATING & ASSOCIATED FACTORS:
food, activity, rest, contain movements; n/v/d,
fever, chills
vi. RELIEVING FACTORS: food, rest, activity,
position, prescribed &/or home remedies,
alternative or complementary therapies
vii. TEMPORAL FACTORS: frequency of
occurrence (single attack, intermittent,
chronic); describe typical attack; change in
, symptom intensity; improvement or
worsening over time
viii. SEVERITY: 0 to 10 scale, effect on lifestyle &
work performance
c. PMHX: past medical history -> general health
over the pts lifetime and disabilities and
functional limitations
i. Hospitalizations &/or surgeries
ii. Gender identity
iii. Major childhood illnesses: congenital heart
defects, cancer, inflammatory bowel disease,
asthma
iv. Major adult illnesses: TB, hepatitis, DM, HTN
MI, parasite diseases
v. Serious injuries: TBI, liver lac, spinal injury,
fxs
vi. Immunizations
vii. Medications: past, current, and recent
medications; complementary and herbal
therapies
viii. Allergies: drugs, foods, environmental
allergens, along with the allergic reactions
ix. Transfusions
x. Emotional status: mood disorders, psychiatric
therapy or meds
xi. Recent screening tests: PAP smear, HPV, HIV,
mammogram, colonoscopy
d. FMH: family history -> parents, grandparents,
and siblings -> significant medical conditions,
cause of death and age of death
i. Notate ethnic & racial background
1) Soap notes documentation. Understanding the
components of Soap note sections. CC, HPI, PMH, FH,
SH, ROS, PE. What information is documented in
these sections.
a. CC: chief complaint -> presenting problem ->
what the patient states. May be stated verbatim in
quotation marks. Always include the duration of
the chief complaint
b. HPI: history of present illness -> detailed
description of sxs that may be r/t the cc ->
OLDCARTS
i. ONSET: when did the problem or sxs first
start; manner of the onset (sudden or
gradual)
ii. LOCATION: exact location (localized,
generalized, radiation patterns)
iii. DURATION: length of problem/episode; if
intermittent, duration of each episode
iv. CHARACTER: nature of pain (stabbing,
burning, sharp, dull, gnawing)
v. AGGRAVATING & ASSOCIATED FACTORS:
food, activity, rest, contain movements; n/v/d,
fever, chills
vi. RELIEVING FACTORS: food, rest, activity,
position, prescribed &/or home remedies,
alternative or complementary therapies
vii. TEMPORAL FACTORS: frequency of
occurrence (single attack, intermittent,
chronic); describe typical attack; change in
, symptom intensity; improvement or
worsening over time
viii. SEVERITY: 0 to 10 scale, effect on lifestyle &
work performance
c. PMHX: past medical history -> general health
over the pts lifetime and disabilities and
functional limitations
i. Hospitalizations &/or surgeries
ii. Gender identity
iii. Major childhood illnesses: congenital heart
defects, cancer, inflammatory bowel disease,
asthma
iv. Major adult illnesses: TB, hepatitis, DM, HTN
MI, parasite diseases
v. Serious injuries: TBI, liver lac, spinal injury,
fxs
vi. Immunizations
vii. Medications: past, current, and recent
medications; complementary and herbal
therapies
viii. Allergies: drugs, foods, environmental
allergens, along with the allergic reactions
ix. Transfusions
x. Emotional status: mood disorders, psychiatric
therapy or meds
xi. Recent screening tests: PAP smear, HPV, HIV,
mammogram, colonoscopy
d. FMH: family history -> parents, grandparents,
and siblings -> significant medical conditions,
cause of death and age of death
i. Notate ethnic & racial background
