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SOAP - Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view)
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.)
Assessment-Diagnosis (determined by combining subjective/objective info)
Plan-Disposition (Admission, Discharge, Transfer instructions)
7 Part...
SOAP - ✔✔ Subjective -HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) Objective -Physical exam, Medical Decision Making (labs, x -rays, etc.) Assessment -Diagnosis (determined by combining subjective/objective info) Plan -Disposition (Admission, Discharge, Transfer instructions) 7 Parts of the HPI - ✔✔ 1. Context 2. Time/Duration; time = course of symptoms (improving, worsening, constant, intermittent, etc.); duration = total ti me symptoms have been present 3. Location 4. Quality 5. Severity 6. Modifying Factors 7. Pertinent positive and negatives Level 5 Chart - ✔✔ HPI: 4 -7 ROS: 10+ PFSH: 2+ PEx: 8+ systems Supination - ✔✔ Turning the hand so that the palm faces upward. Volar - ✔✔ Pertaining to the palm of the hand or the sole of the foot. Inferior - ✔✔ Situated below or further away from the head. Midline - ✔✔ Line that divides the body into right and left halves. Abduction - ✔✔ Moving away from the midline. ACLS - ✔✔ Advanced cardiac life support. AMA - ✔✔ Against medical advice. DNR - ✔✔ do not resuscitate DOA - ✔✔ Dead on arrival OSH - ✔✔ Outside hospital PCP - ✔✔ Primary care physician PTA - ✔✔ Prior to arrival UTD - ✔✔ Up to date (as in immunizations) WNL - ✔✔ within normal limits yo - ✔✔ year old B/L - ✔✔ bilateral D/C - ✔✔ discharge H&P - ✔✔ history & physical nl - ✔✔ normal s/p - ✔✔ status post TTP - ✔✔ tenderness to palpation Proximal - ✔✔ closer to the body Lateral - ✔✔ farther from the midline Extension - ✔✔ straightening out Distal - ✔✔ farther from the body Adduction - ✔✔ Draws toward the midline Pronation - ✔✔ turning of the hand so the palm faces downward Posterior - ✔✔ situated behind or directed towards the rear Plantar - ✔✔ referring to the sole of the foot Inverted - ✔✔ turned inward Deep - ✔✔ Farther from the surface Flexion - ✔✔ bending or angulation
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