SOAP NOTES AND CULTURAL COMPETENCY
QUESTIONS AND ANSWERS
100% CORRECT SCORED A+
1. Focused Exam:
Answer: -Patient encounter where the "focus" is on the patient's chief complaint
-are documented in a SOAP NOTE
-SOAP notes are not complete History & Physicals
-perform this
-problem oriented
-only ask questions related to chief complaint
-what brings patient to this visit
2. S:
Answer: Anything the patient or family
tell you Chief Complaint & Duration
,HPI- include SLIDTA
History-PMH, PSH, Medications, Allergies
Chief complaint:
HPI:
Significant PMH/PSH:
Allergies:
Medications:
Social: who do you live with, do you have significant other?
Smoking:
ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize CAGE) Do you drink alcohol? How much? Living
environment: (Ask If there is an area of concern) - do you feel safe, are you afraid in your own home?
-ab pain we don't care about cataract surgery, not relevant
3. CAGE:
Answer: Cutting down, annoyance when asked about drinking, Guilt do you feel guilty about it, Eye opener - to
get you going in the morning
-if response is 2/4 needs further evaluation
4. Chief Complaint:
Answer: Limited to one complaint, most pressing Brief- as
,few words as possible
Duration always included
Example: Sore throat for 2 days
-why they are here
ex: fevers , chills, nausea (associated sx) but PAIN is the main thing, most important
-anyone who presents with painful urination always question STD/STI, ask about discharge, sexual activity, check back
for CVA tenderness
ex: constipation, ear pain, otitis media, pharyngitis
-to determine the reason patient seeks care
-important to consider using the patient's terminology
-provides "title" for the encounter
-what brings you to the oflce? why did the symptom bring you to the oflce?
-describe it like you would to a relative or neighbor
5. History of Present Illness
Answer:: -Follows the Chief Complaint
-Always starts with: "This is a (age/race/sex)
-Narrative statement
-You ask the appropriate questions and record the patient's responses.
, -You guide the patient to answer your questions.
-Include SLIDTA
-Ditterence between SOAP and H&P: associated symptoms go in body of HPI
-This is a 52 year old African American male who presents today with....
-If fever - always write temp max
-Patients' positive response to ROS is recorded as reports..........
Patients' negative response to ROS is recorded as denies.......
Omit: "he" "she" "patient" "patient states"
-Gather information in an orderly fashion to come to a diagnosis
-90% of the time the diagnosis is made by the end of the HPI (assuming that you have asked the correct questions)
-Learning how to ask the right questions is key
-Don't write "here" or "with complaints"
-"Reports not sexually active." Easy way out for course
-In the body of this in a soap note: may include medications, past medical, past surgical and social if relevant to chief
complaint - or can write below this
-Include reverent review of systems
-Must write year when meds were started - must include, if they don't know write "unknown start date"
-Drug, food, seasonal and environmental allergies - latex
QUESTIONS AND ANSWERS
100% CORRECT SCORED A+
1. Focused Exam:
Answer: -Patient encounter where the "focus" is on the patient's chief complaint
-are documented in a SOAP NOTE
-SOAP notes are not complete History & Physicals
-perform this
-problem oriented
-only ask questions related to chief complaint
-what brings patient to this visit
2. S:
Answer: Anything the patient or family
tell you Chief Complaint & Duration
,HPI- include SLIDTA
History-PMH, PSH, Medications, Allergies
Chief complaint:
HPI:
Significant PMH/PSH:
Allergies:
Medications:
Social: who do you live with, do you have significant other?
Smoking:
ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize CAGE) Do you drink alcohol? How much? Living
environment: (Ask If there is an area of concern) - do you feel safe, are you afraid in your own home?
-ab pain we don't care about cataract surgery, not relevant
3. CAGE:
Answer: Cutting down, annoyance when asked about drinking, Guilt do you feel guilty about it, Eye opener - to
get you going in the morning
-if response is 2/4 needs further evaluation
4. Chief Complaint:
Answer: Limited to one complaint, most pressing Brief- as
,few words as possible
Duration always included
Example: Sore throat for 2 days
-why they are here
ex: fevers , chills, nausea (associated sx) but PAIN is the main thing, most important
-anyone who presents with painful urination always question STD/STI, ask about discharge, sexual activity, check back
for CVA tenderness
ex: constipation, ear pain, otitis media, pharyngitis
-to determine the reason patient seeks care
-important to consider using the patient's terminology
-provides "title" for the encounter
-what brings you to the oflce? why did the symptom bring you to the oflce?
-describe it like you would to a relative or neighbor
5. History of Present Illness
Answer:: -Follows the Chief Complaint
-Always starts with: "This is a (age/race/sex)
-Narrative statement
-You ask the appropriate questions and record the patient's responses.
, -You guide the patient to answer your questions.
-Include SLIDTA
-Ditterence between SOAP and H&P: associated symptoms go in body of HPI
-This is a 52 year old African American male who presents today with....
-If fever - always write temp max
-Patients' positive response to ROS is recorded as reports..........
Patients' negative response to ROS is recorded as denies.......
Omit: "he" "she" "patient" "patient states"
-Gather information in an orderly fashion to come to a diagnosis
-90% of the time the diagnosis is made by the end of the HPI (assuming that you have asked the correct questions)
-Learning how to ask the right questions is key
-Don't write "here" or "with complaints"
-"Reports not sexually active." Easy way out for course
-In the body of this in a soap note: may include medications, past medical, past surgical and social if relevant to chief
complaint - or can write below this
-Include reverent review of systems
-Must write year when meds were started - must include, if they don't know write "unknown start date"
-Drug, food, seasonal and environmental allergies - latex
