21 Questions
What does the term 'subjective' refer to in patient assessment?
What the patient tells you
What is the acronym SOAP stand for in the SOAP format?
Subjective, Objective, Assessment, Plan
What percentage of diagnoses can be made based on history alone?
70%
The chief complaint is recorded in __________.
quotations
Match the term with its description:
HPI = History of present illness ROS = Review of systems SOAP = Subjective, Objective, Assessment, Plan
What does the SOAP format stand for in medical documentation?
Subjective, Objective, Assessment, Plan
What type of data is subjective data?
Data provided by the patient
___ is what the patient tells you, while objective is what you are observing.
Subjective
Match the following components with their description:
HPI = History of present illness ROS = Review of systems Onset = When did the symptom start? Location = Specific site of the symptom
How much percentage of diagnoses can be made based on history alone?
70%
What is the subjective component in the SOAP format?
Subjective is what the patient tells you.
According to the information provided, how much of diagnoses can be made based on history alone?
70%
What is the objective component in the SOAP format?
Objective is what we are noting.
What does HPI stand for?
History of Present Illness
Subjective information is recorded in ______.
quotations
Match the following with their descriptions:
Onset = When did it start? Duration = How long has it lasted? Location = Specific location is very helpful. Characteristics = Describing the nature of the symptom. Aggravating and alleviating factors = What makes the symptom worse or better.
What does the subjective data in a SOAP format refer to?
What the patient tells you
What percentage of diagnoses can be made based on history alone?
70%
The objective part of a patient assessment includes what the patient reports.
False
What does ROS stand for?
review of systems
Match the following HPI components with their descriptions:
Onset = When did it start? Location = Specific location of the symptom Duration = How long has it lasted? Characteristics = Describing the nature of the symptom Aggravating and alleviating factors = What makes it worse or better?
Study Notes
SOAP Format
- The SOAP format is a framework for organizing patient data, consisting of subjective, objective, assessment, and plan.
Subjective Data
- Patient's chief complaint, history of present illness (HPI), and review of systems (ROS) provide the subjective data.
- 70% of diagnoses can be made based on history alone.
- Subjective information is recorded in quotations.
- Chief complaint: what brings the patient to the healthcare provider, what is the problem?
- HPI includes:
- Onset: when did the symptoms start?
- Duration: how long have the symptoms lasted?
- Location: specific location of symptoms
- Characteristics: description of symptoms (e.g., worsening, severity, type of pain)
- Aggravating and alleviating factors: what makes symptoms worse or better?
- Associated symptoms: symptoms related to differentials
- Review of systems (ROS) is organized by system:
- Constitutional
- Head to toe
- Neurological
- Cardiac
- Respiratory
- GI
- GU
- Musculoskeletal
- ROS includes specific questions for each body system.
Objective Data
- Objective data includes:
- Mental status exam
- Physical assessment
- Labs
- Vital signs
- Screening tools
- Imaging
Importance of Subjective Data
- Subjective data provides a good idea of what's going on most of the time.
- Adding physical exam to subjective data can lead to 90% of diagnoses being made.
SOAP Format
- The SOAP format is a framework for organizing patient data, consisting of subjective, objective, assessment, and plan.
Subjective Data
- Patient's chief complaint, history of present illness (HPI), and review of systems (ROS) provide the subjective data.
- 70% of diagnoses can be made based on history alone.
- Subjective information is recorded in quotations.
- Chief complaint: what brings the patient to the healthcare provider, what is the problem?
- HPI includes:
- Onset: when did the symptoms start?
- Duration: how long have the symptoms lasted?
- Location: specific location of symptoms
- Characteristics: description of symptoms (e.g., worsening, severity, type of pain)
- Aggravating and alleviating factors: what makes symptoms worse or better?
- Associated symptoms: symptoms related to differentials
- Review of systems (ROS) is organized by system:
- Constitutional
- Head to toe
- Neurological
- Cardiac
- Respiratory
- GI
- GU
- Musculoskeletal
- ROS includes specific questions for each body system.
Objective Data
- Objective data includes:
- Mental status exam
- Physical assessment
- Labs
- Vital signs
- Screening tools
- Imaging
Importance of Subjective Data
- Subjective data provides a good idea of what's going on most of the time.
- Adding physical exam to subjective data can lead to 90% of diagnoses being made.
SOAP Format
- The SOAP format is a framework for organizing patient data, consisting of subjective, objective, assessment, and plan.
Subjective Data
- Patient's chief complaint, history of present illness (HPI), and review of systems (ROS) provide the subjective data.
- 70% of diagnoses can be made based on history alone.
- Subjective information is recorded in quotations.
- Chief complaint: what brings the patient to the healthcare provider, what is the problem?
- HPI includes:
- Onset: when did the symptoms start?
- Duration: how long have the symptoms lasted?
- Location: specific location of symptoms
- Characteristics: description of symptoms (e.g., worsening, severity, type of pain)
- Aggravating and alleviating factors: what makes symptoms worse or better?
- Associated symptoms: symptoms related to differentials
- Review of systems (ROS) is organized by system:
- Constitutional
- Head to toe
- Neurological
- Cardiac
- Respiratory
- GI
- GU
- Musculoskeletal
- ROS includes specific questions for each body system.
Objective Data
- Objective data includes:
- Mental status exam
- Physical assessment
- Labs
- Vital signs
- Screening tools
- Imaging
Importance of Subjective Data
- Subjective data provides a good idea of what's going on most of the time.
- Adding physical exam to subjective data can lead to 90% of diagnoses being made.
SOAP Format
- SOAP stands for Subjective, Objective, Assessment, and Plan
- Subjective data comes from the patient (chief complaint, history of present illness, review of systems)
- 70% of diagnoses can be made based on history alone, and 90% with the addition of physical exam
Subjective Data
- Chief complaint: what brings the patient to the doctor
- History of present illness (HPI): onset, location, duration, characteristics, aggravating and alleviating factors, radiation, timing, and severity
- Review of systems (ROS): organized by system (constitutional, head to toe, neurological, cardiac, respiratory, GI, GU, and musculoskeletal)
- ROS asks specific questions about each body system, but does not document denies history
Objective Data
- Mental status exam
- Physical assessment
- Labs
- Vital signs
- Screening tools
- Imaging (e.g., x-rays, MRI, CT)
Assessment
- Primary diagnosis
- Differential diagnoses
- What we think is going on, and what we know is going on
Plan
- Prescription
- Imaging or diagnostic procedures
- Teaching
- Referrals
- Follow-up
- ER precautions
Traditional H&P vs. Focused Exam
- Traditional H&P: comprehensive, detailed, and time-consuming
- Focused exam: depends on the context (established patient, specific chief complaint)
- Focused exam may not include a full physical assessment (e.g., no elaborate musculoskeletal exam)
Comprehensive vs. Focused
- Comprehensive: for new patients, baseline for future visits and assessments, primary prevention, and secondary prevention
- Focused: for established patients, treating a specific ailment or chief complaint, tailoring the exam and documentation to the chief complaint
Learn about the SOAP format, including subjective and objective data, and their importance in medical diagnostics. Understand how patient history and physical assessment contribute to accurate diagnoses.
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