Study Guide for Final Exam: NURS 6800
General topics include, but are not limited to:
Well child examination:
❖ Well visits including months 1, 2, 4, 6, 9, and 12, 15, 18, 24,
❖ SOAP notes: Meanings of SOAP:
❖ S: what the parent reports O: your assessment A: your diagnosis P: the plan
This is the first heading of the SOAP note. Documentation under this heading comes from the
“subjective” experiences, personal views or feelings of a patient or someone close to them. In
the inpatient setting, interim information is included here. This section provides context for
the Assessment and Plan.
Chief Complaint (CC)
The CC or presenting problem is reported by the patient. This can be a symptom, condition,
previous diagnosis or another short statement that describes why the patient is presenting today.
The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the
document will entail.
• Examples: chest pain, decreased appetite, shortness of breath.
However, a patient may have multiple CC’s, and their first complaint may not be the most
significant one. Thus, physicians should encourage patients to state all of their problems, while
paying attention to detail to discover the most compelling problem. Identifying the main problem
must occur to perform effective and efficient diagnosis.
History of Present Illness (HPI)
The HPI begins with a simple one line opening statement including the patient's age, sex and
reason for the visit.
• Example: 47-year old female presenting with abdominal pain.
This is the section where the patient can elaborate on their chief complaint. An acronym often
used to organize the HPI is termed “OLDCARTS”:
• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
, • Alleviating and Aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the
patient rate the CC?
It is important for clinicians to focus on the quality and clarity of their patient's notes, rather than
include excessive detail.
History
• Medical history: Pertinent current or past medical conditions
• Surgical history: Try to include the year of the surgery and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history
of every person in the patient's family.
• Social History: An acronym that may be used here is HEADSS which stands for
Home and Environment; Education, Employment, Eating; Activities; Drugs;
Sexuality; and Suicide/Depression.
Review of Systems (ROS)
This is a system based list of questions that help uncover symptoms not otherwise mentioned by
the patient.
• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia
• Musculoskeletal: Toe pain, decreased right shoulder range of motion
Current Medications, Allergies
Current medications and allergies may be listed under the Subjective or Objective sections.
However, it is important that with any medication documented, to include the medication name,
dose, route, and how often.
• Example: Motrin 600 mg orally every 4 to 6 hours for 5 days
o
o Objective
This section documents the objective data from the patient encounter. This includes:
• Vital signs
, • Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.
A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's
subjective description and should be documented under the subjective heading, while a sign is an
objective finding related to the associated symptom reported by the patient. An example of this is
a patient stating he has “stomach pain,” which is a symptom, documented under the subjective
heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the
objective heading.
o Assessment
This section documents the synthesis of “subjective” and “objective” evidence to arrive at a
diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible
interaction of the problems, and changes in the status of the problems. Elements include the
following.
Problem
List the problem list in order of importance. A problem is often known as a diagnosis.
Differential Diagnosis
This is a list of the different possible diagnosis, from most to least likely, and the thought
process behind this list. This is where the decision-making process is explained in depth.
Included should be the possibility of other diagnoses that may harm the patient, but are less
likely.
❖ Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1
(described in the plan below). Repeat for additional problems
o Plan
This section details the need for additional testing and consultation with other clinicians to
address the patient's illnesses. It also addresses any additional steps being taken to treat the
patient. This section helps future physicians understand what needs to be done next. For each
problem:
• State which testing is needed and the rationale for choosing each test to resolve
diagnostic ambiguities; ideally what the next step would be if positive or negative
• Therapy needed (medications)
• Specialist referral(s) or consults
General topics include, but are not limited to:
Well child examination:
❖ Well visits including months 1, 2, 4, 6, 9, and 12, 15, 18, 24,
❖ SOAP notes: Meanings of SOAP:
❖ S: what the parent reports O: your assessment A: your diagnosis P: the plan
This is the first heading of the SOAP note. Documentation under this heading comes from the
“subjective” experiences, personal views or feelings of a patient or someone close to them. In
the inpatient setting, interim information is included here. This section provides context for
the Assessment and Plan.
Chief Complaint (CC)
The CC or presenting problem is reported by the patient. This can be a symptom, condition,
previous diagnosis or another short statement that describes why the patient is presenting today.
The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the
document will entail.
• Examples: chest pain, decreased appetite, shortness of breath.
However, a patient may have multiple CC’s, and their first complaint may not be the most
significant one. Thus, physicians should encourage patients to state all of their problems, while
paying attention to detail to discover the most compelling problem. Identifying the main problem
must occur to perform effective and efficient diagnosis.
History of Present Illness (HPI)
The HPI begins with a simple one line opening statement including the patient's age, sex and
reason for the visit.
• Example: 47-year old female presenting with abdominal pain.
This is the section where the patient can elaborate on their chief complaint. An acronym often
used to organize the HPI is termed “OLDCARTS”:
• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
, • Alleviating and Aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the
patient rate the CC?
It is important for clinicians to focus on the quality and clarity of their patient's notes, rather than
include excessive detail.
History
• Medical history: Pertinent current or past medical conditions
• Surgical history: Try to include the year of the surgery and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history
of every person in the patient's family.
• Social History: An acronym that may be used here is HEADSS which stands for
Home and Environment; Education, Employment, Eating; Activities; Drugs;
Sexuality; and Suicide/Depression.
Review of Systems (ROS)
This is a system based list of questions that help uncover symptoms not otherwise mentioned by
the patient.
• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia
• Musculoskeletal: Toe pain, decreased right shoulder range of motion
Current Medications, Allergies
Current medications and allergies may be listed under the Subjective or Objective sections.
However, it is important that with any medication documented, to include the medication name,
dose, route, and how often.
• Example: Motrin 600 mg orally every 4 to 6 hours for 5 days
o
o Objective
This section documents the objective data from the patient encounter. This includes:
• Vital signs
, • Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians.
A common mistake is distinguishing between symptoms and signs. Symptoms are the patient's
subjective description and should be documented under the subjective heading, while a sign is an
objective finding related to the associated symptom reported by the patient. An example of this is
a patient stating he has “stomach pain,” which is a symptom, documented under the subjective
heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the
objective heading.
o Assessment
This section documents the synthesis of “subjective” and “objective” evidence to arrive at a
diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible
interaction of the problems, and changes in the status of the problems. Elements include the
following.
Problem
List the problem list in order of importance. A problem is often known as a diagnosis.
Differential Diagnosis
This is a list of the different possible diagnosis, from most to least likely, and the thought
process behind this list. This is where the decision-making process is explained in depth.
Included should be the possibility of other diagnoses that may harm the patient, but are less
likely.
❖ Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1
(described in the plan below). Repeat for additional problems
o Plan
This section details the need for additional testing and consultation with other clinicians to
address the patient's illnesses. It also addresses any additional steps being taken to treat the
patient. This section helps future physicians understand what needs to be done next. For each
problem:
• State which testing is needed and the rationale for choosing each test to resolve
diagnostic ambiguities; ideally what the next step would be if positive or negative
• Therapy needed (medications)
• Specialist referral(s) or consults
