ANSWERS GRADED A+ UNIVERSITY OF
ALABAMA
What does SOAP stand for
subjective, objective, assessment, plan
What does OLDCARTS stand for?
Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Relieving factors
Timing/temporal factors/treatment
Severity
subjective
CC, HPI, PMH, FH, SH, ROS
,objectives
General appearance, vital signs, full physical exam, present lab/test data
assessment
problem list & differential diagnoses
plan
Diagnostic/screening tests ordered or pending
Rx or supportive treatment: for meds, give trade and generic names and
specific dose; include caretaker responsibilities (e.g. dressing changes, diary
of headaches, humidification, etc.); include immunizations and management
of reactions (i.e. parent instructed to give prophylactic acetaminophen).
RTC (return to clinic) or follow up date. Indicate need for consultation and/or
referral.
What is evidence-based practice (EBP)?
A lifelong problem-solving approach to patient care that combines the best current
evidence with clinician expertise and patient preferences.
What are the benefits of EBP?
Improves quality of care, patient outcomes, population health, and cost-
effectiveness.
,How many dimensions of wellness should clinicians assess?
All 10 dimensions.
List the 10 dimensions of wellness.
Physical, Emotional, Financial, Intellectual, Career, Social, Creative,
Environmental, Spiritual, Digital.
What can result from failing to assess all dimensions of wellness?
Incomplete assessments, inaccurate conclusions, and ineffective management
plans.
What is the first step in the EBP process?
Cultivate a spirit of inquiry within an EBP culture and environment.
What does PICOT stand for?
P = Patient population, I = Intervention or issue of interest, C = Comparison
intervention, O = Outcome, T = Time frame.
What is the purpose of systematically searching for evidence?
, To find the strongest available evidence, starting with systematic reviews and
meta-analyses.
What are the criteria for critically appraising evidence?
Validity, Reliability, Applicability.
What is the importance of integrating evidence with clinical expertise?
To interpret evidence within the context of the patient's history, presentation, and
values.
What should clinicians evaluate after implementing an EBP intervention?
Whether the intervention improved patient outcomes.
What is validity in the context of assessment?
Determines whether an assessment measures what it is intended to measure.
Define reliability in assessments.
Measures consistency of results.
What does sensitivity refer to in testing?