SOAP Note: Subjective Portions Overview

SOAP Note Subjective Portions: Chief Complaint, HPI, ROS, and Histories

• Chief Complaint (CC): The primary reason a patient seeks medical attention. It's subjective and concisely states the patient's reason for the visit. The CC should clearly communicate why the patient is seeing the physician, using medical terminology whenever possible, or direct patient quotes, if allowed.

• History of Present Illness (HPI): Provides a detailed, chronological description of the patient's current health issue(s). The HPI delves into the problems, symptoms, and conditions leading to the visit. It includes details like onset, timing, current status, location, quality, severity, quantity, modifying factors, associated symptoms, and relevant context. The HPI gathers relevant patient information through both patient self-reporting and physician-driven questioning.

• Review of Systems (ROS): A head-to-toe checklist of all reported symptoms, whether positive (present) or negative (absent) during the patient encounter. It's crucial for a comprehensive picture of the patient's current state. The ROS should cover all symptoms that are detailed in the HPI. It does not provide new information; it reflects and corroborates (or refutes) the information in the HPI. 

• Histories: This section encompasses a detailed patient history.

• Past Medical History (PMH): Includes general health, childhood illnesses, allergies, hospitalizations, immunizations, accidents, pregnancies, birth control, and any relevant prior health information.

• Past Surgical History (PSH): Records all past surgeries and procedures performed.

• Social History (SH): Includes sociodemographic factors impacting health, such as living arrangements, occupation, marital status, children, substance use (alcohol, tobacco, others), travel history, and pet exposures.

• Family History (FH): Details diseases, conditions, and longevity of immediate and sometimes extended biological family members.

True/False Questions

• Statements regarding the HPI: Describing the onset and duration of symptoms is crucial for a thorough HPI. (True)
• Explanation: Correct. These details allow for a timeline and better understanding of the problem.
• Statements regarding the ROS: The ROS should include symptoms not mentioned in the HPI. (False)
• Explanation: Incorrect. The ROS reflects symptoms discussed or addressed during the patient visit. Including symptoms not discussed would contradict the information in the HPI.

Multiple Choice Questions

• Question: In a SOAP note, which section primarily focuses on the subjective reason for the patient visit?

• a) Past Medical History

• b) Review of Systems

• c) Past Surgical History

• d) Chief Complaint

• Correct Answer (d): The Chief Complaint is the subjective reason for the visit.

• Explanation (a): Incorrect. PMH offers objective historical medical information.

• Explanation (b): Incorrect. ROS covers reported symptoms, not reasons for the encounter.

• Explanation (c): Incorrect. PSH is about the patient's operations, not the reason for seeing a doctor.

• Question: What detail is NOT typically included in the Chief Complaint?

• a) Patient's primary concern

• b) Objective findings from the physical exam

• c) Symptoms that brought the patient in for care.

• d) New patient status for treatment

• Correct Answer (b): Objective findings are discussed in the physical examination, not the chief complaint.

• Explanation (a): Incorrect; Patient's primary concern is part of the CC

• Explanation (c): Incorrect; Symptoms are the essence of the CC

• Explanation (d): Incorrect; New patient status is a valid primary concern and chief complaint.

• Question: What section provides a detailed chronological account of symptoms during the patient encounter?

• a) ROS

• b) HPI

• c) PMH

• d) PSH

• Correct Answer (b): HPI (History of Present Illness) records the symptoms' development over time.

• Explanation (a): incorrect- ROS is a system review with symptoms listed

• Explanation (c): incorrect- PMH covers prior medical conditions

• Explanation (d): incorrect- PSH summarizes past surgical history.

Matching Questions

Match the term with the correct description:

This quiz covers the subjective components of SOAP notes, focusing on the Chief Complaint, History of Present Illness, and Review of Systems. You'll learn how to effectively document patient information and the significance of each section in patient care. Perfect for medical students and healthcare professionals alike.