Interview Skills and SOAP Notes

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Questions and Answers

What is included in the Subjective section of a SOAP note?

Clinician's observations during the physical exam

Treatment plan and recommendations

Patient's medical history and concerns (correct)

Vital signs and lab results

What is the primary purpose of Open-ended skills in an interview?

To enable the patient to share their concerns freely (correct)

To provide immediate treatment options

To restrict the patient's responses to specific queries

To gather quantitative data for assessments

How much time should be forecasted for the interview during the agenda setting?

30 minutes

1-2 minutes (correct)

5-10 minutes

10-20 minutes

Which of the following is NOT included in the Objective section of a SOAP note?

Patient's symptoms Signup and view all the answers

What should focusing skills help to gather during an interview?

Symptom story, personal context, and emotional context Signup and view all the answers

What is the purpose of orienting the patient to the end of the interview?

To prepare the patient for the conclusion of the discussion. Signup and view all the answers

Which of the following is a recommended practice when explaining treatment options to a patient?

To incorporate the patient's preferences into the discussion. Signup and view all the answers

What does a score of 6 or less on the functional reach test indicate?

Increased risk for falls. Signup and view all the answers

What constitutes instrumental ADL according to the assessment?

Tasks like using the phone and managing finances. Signup and view all the answers

Which of the following best reflects the differential between normal aging and acute disease symptoms?

Normal aging changes can predispose to diseases. Signup and view all the answers

What is emphasized in the guidelines for SOAP documentation?

Clarity and conciseness in writing. Signup and view all the answers

Which group of symptoms is most commonly reported in geriatric assessments for men?

Arthritis, hypertension, deafness. Signup and view all the answers

What should be done before concluding an interview with a patient?

Summarize decisions and provide written instructions. Signup and view all the answers

Which tools are specifically used for assessing depression in individuals aged 12 years and older?

PHQ-9 and PHQ-A Signup and view all the answers

What does the 'D' in the OLD CHARTS acronym stand for when assessing depression?

Duration Signup and view all the answers

What type of history is assessed through the Past Medical History (PMH)?

Current medications Signup and view all the answers

Which of the following screening tools is NOT typically used for substance use assessment in adults?

GDS Signup and view all the answers

In the context of social history, which aspect is NOT typically included?

Family history of diseases Signup and view all the answers

What does the acronym ROS stand for in a mental health assessment?

Review of Symptoms Signup and view all the answers

Which part of the mental health assessment focuses on the patient's appearance and speech?

Objective examination Signup and view all the answers

Which of the following is NOT considered an aspect of the subjective mental health assessment?

Cognitive exam Signup and view all the answers

What does the 'R' in OLD CHARTS indicate regarding a patient's condition?

Relieving factor Signup and view all the answers

Which of the following is NOT a component of the Geriatric Depression Scale (GDS)?

Severity Signup and view all the answers

Study Notes

Interview and SOAP Notes

Prepare for interviews by reviewing patient charts, intake forms, and questionnaires.
Set the stage for the interview (30-60 seconds).
Elicit the patient's chief concern and establish an agenda (1-2 minutes).
Indicate the available time and forecast the interview's process.
Use non-focusing skills initially to help the patient express themselves (30-60 seconds).
Employ open-ended questions to collect data from nonverbal cues.
Use focusing skills to gather the symptom story, personal context, and emotional context (3-10 minutes).
Obtain a chronological description of the HPI (History of Present Illness) without interpretation. Use OLD CHARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity).
Obtain past medical history (PMH), past surgical history (PSH), family history (FH), and social history (SH). Include screening status.
Collect information regarding health, diet, physical activity, sexual history, substance use, health literacy, occupation, lifestyle, legal issues, safety, support systems.
Conduct a review of systems (ROS) for all body systems.
Orient the patient to the interview's conclusion and obtain permission for discussion.
Explain the diagnosis and prognosis.
Facilitate shared decision-making regarding tests and treatment options.
Summarize decisions and provide written plans and instructions.
Acknowledge and support the patient before ending the interview.

SOAP Format

Maintain a concise and clear SOAP note.
Use medical terms if appropriate.
Document all pertinent positives and negatives.
Include the following in the subjective section (S): chief complaint (CC), history of present illness (HPI), past medical/surgical history (PMH/PSH), family history (FH), social history (SH), and review of systems (ROS).
Include objective findings (O) from physical exams (including observations from other clinicians), vital signs, height, weight, BMI, labs, and imaging results.
Provide an assessment (A) of the diagnosis(es).
Develop a plan (P) for treatment, medications, labs, and imaging, consultations, and referrals. Include instructions and patient education.

Mental Health in Primary Care

Conduct mental health screenings for anxiety (in children aged 8-18) and depression (in all patients aged 12 and older). Emphasize substance use screenings for adults (18+).
Use screening tools such as SCARED (children), Social Phobia Inventory, PHQ-9/PHQ-A/GDS/EPDS, NIDA quick screen, TAPS, AUDIT-C, SASQ.
Assess mental health conditions; refer to psychiatry for complex cases.
Collaborate with healthcare professionals and refer patients at high risk.
Thoroughly assess sleep, appetite, energy, family life, relationships, work, and education history, as well as the ROS related to psychiatry and cognitive factors.
Include psychiatric history, mental status exam (MSE), cognitive exam, and abbreviated physical exam in the objective section.

Geriatric Health

Differentiate age-related physiological changes from acute or chronic disease.
Multifactorial conditions involve identifiable stressors and age-related risk factors.
Common modifiable risk factor for falls is polypharmacy, which requires thorough medication history, including prescription/OTC/PRN medications, vitamins, and supplements. Address adherence, and consider drug interactions.
Use the BEERS criteria to evaluate medication appropriateness for older adults.
Conduct a nutritional assessment to identify malnutrition risks and address dietary history and access to food.
Assess vision and hearing using appropriate tests and instruments.
Assess cognitive function (e.g., memory) for issues such as delirium and dementia.
Evaluate functional status using activities of daily living (ADL) and instrumental activities of daily living (IADL) scales.
Address and screen for depression and evaluate risk factors.
Review and reconcile medications regularly.
Discuss goals of care.
Consider advanced directives (e.g., MOLST).

Genital Health

Consent and chaperones are essential for examinations of genitalia.
Obtain consent in sensitive examinations.
Chaperones are recommended for all intimate exams, regardless of provider or patient gender identity.
Include menstrual/pregnancy/STI history and gynecological procedures.
Conduct cervical cancer screening where appropriate.
Examine the genitalia for hygiene, products/soaps/creams/medications used, and any procedures/piercings.
Examine breasts with a CBE/SBE. Use a systematic approach.
Examine axillae in breast exams (inspect, palpate).
Conduct genital exams, including those for infants and young toddlers, appropriately.
Assess sexual health, orientation, gender identity, relationships, and sexual practices.
Review contraceptive use, including types, duration, and satisfaction.
Evaluate and document results for both AMAB and AFAB individuals with comprehensive exams.

Respiratory Health

Assess respiratory rate, rhythm, and depth in patients. Note any assisted breathing, oxygen use, or ambulation difficulty.
Identify and palpate tender lung areas.
Perform percussion (listening to body sounds) and auscultation (listening through stethoscope) to assess lung and respiratory sounds and variations.
Identify tactile fremitus (palpable vibrations) bilaterally.
Note any abnormal breath sounds (wheeze, rhonchi, crackles, pleural rubs, stridor), which helps isolate the location of lung issues.
Perform appropriate hearing tests (whisper, finger rub, Weber, and Rinne) as part of evaluating respiratory issues.

Cardiovascular Health

Assess cardiac health through history taking, vital signs, physical examination.
Perform a detailed cardiac physical exam, including palpation and auscultation.
Note S1, S2, S3, and S4 heart sounds.
Listen for any murmurs resulting from blood flow disturbances.
Evaluate the patient's heart rate (palpate or auscultate) for any irregularities.
Assess JVP (Jugular venous pressure) to determine fluid buildup in the cardiovascular system.

Neurological Health

Evaluate the cranial nerves (CNs), including smell, sight, eye movements, facial sensation.
Assess hearing (whispering, tuning fork tests) and swallowing (inspection/palpation).
Note speech and cognitive factors.
Assess muscle strength and sensory function, cognitive functions using MOCA and MMSE.
Perform sensory assessments including light touch, sharp/dull, and temperature.
Evaluate reflexes (deep tendon reflexes and superficial reflexes).
Assess gait and balance (e.g., tandem walk).

Abdominal System

Establish a thorough history, including current medications (anticholinergic, SSRI, metformin, GLP-1, NSAIDs, PPI) and relevant allergies.
Assess pain location, quality, characteristics, and radiation patterns.
Note characteristics such as bowel sounds (hyperactive, hypoactive, absent, borborygmi, succussion splash, high-pitched rushing), vessel bruits/murmurs, and potential peritonitis symptoms (guarding, rebound tenderness, rigidity).
Assess the liver (size, palpation, tenderness), spleen (size, palpation, tenderness), kidneys (palpation, tenderness), and bladder (palpation/percussion).
Percuss for tympany/dullness.
Palpate for masses, tenderness, guarding, and rigidity.
Use percussion and palpation for appropriate organ evaluation.
Assess characteristics of pain and tenderness with respect to location.

Skin, Hair, and Nails Assessment

Perform a thorough skin examination, noting possible signs and symptoms of various skin problems and taking into account potential risks of skin cancer. Evaluate location, size, shape, symmetry, color, border, and configuration of lesions.
Palpate for tenderness, surface texture, elevation, skin thickness, blanching, tissue loss, tethering, temperature, and edema.
Assess nail and hair characteristics, noting any abnormal growths, colors, or configurations.
Evaluate the integumentary system for any lesions and note color variations and skin integrity.

MSK Health

Assess joint symmetry, deformity, edema, atrophy, erythema, and skin changes for potential musculoskeletal conditions.
Palpate for key anatomic landmarks on the musculoskeletal system.
Evaluate the range of motion (ROM) using both active and passive methods to assess joint mobility, flexibility, and stability.
Perform specific musculoskeletal tests (e.g., straight leg raise, Spurling, Speed's, Yergason's) to identify possible pathologies.
Assess the strength and tone of muscles for abnormalities.
Note special characteristics like heat, crepitus, swelling, guarding, tenderness, and referred tenderness in the musculoskeletal area.
Perform pertinent special tests depending on presenting concerns.

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Description

This quiz assesses your understanding of crucial components in SOAP notes and effective interview techniques. Questions cover subjective and objective elements of SOAP notes, the use of open-ended questions in interviews, and time management during the interview process. Test your knowledge on these essential topics.