EPC exam 1
History & physical (H &P) or Admit note - ANSRecord of initial office visit or admission to hospital. Fairly
extensive bc first visit
Chief complaint - ANSShould b quote from pt (use "), their own words
H&P - ANSArranged like SOAP note but more comprehensive
SOAP note or progress note - ANSReturn office visit or during hospital rounds, more brief & focused.
Addresses prob pt being seen for
H & P Admit not - ANSComp health history & physical exam
1. Chief complaint
2. HPI
3. Past med history
4. Family history
5. Social history
6. ROS
7. Physical exam (lab, xray)
8. Assesment
9. Plan
HPI - ANSIn paragraph form using sentences, tells story of pt. illness
Remainder of note - ANSBulletted
SOAP - ANSMedical legal docu, form of comnxn, imp for payment
S= subjective. Wht pt, nurses, therapists, other hc workers say
History & physical (H &P) or Admit note - ANSRecord of initial office visit or admission to hospital. Fairly
extensive bc first visit
Chief complaint - ANSShould b quote from pt (use "), their own words
H&P - ANSArranged like SOAP note but more comprehensive
SOAP note or progress note - ANSReturn office visit or during hospital rounds, more brief & focused.
Addresses prob pt being seen for
H & P Admit not - ANSComp health history & physical exam
1. Chief complaint
2. HPI
3. Past med history
4. Family history
5. Social history
6. ROS
7. Physical exam (lab, xray)
8. Assesment
9. Plan
HPI - ANSIn paragraph form using sentences, tells story of pt. illness
Remainder of note - ANSBulletted
SOAP - ANSMedical legal docu, form of comnxn, imp for payment
S= subjective. Wht pt, nurses, therapists, other hc workers say
