S.O.A.P Subjective and Objective

Physical exam findings -> neurological cerebellar

Cerebellar exams Romberg test = test balance standing up Finger nose test = can you touch your nose, the doctors finger and back to your nose? Heel to shin = can you bring your heel up the length of your shin Pronator drift = arm moves away when it is up Rapid alternating movements = hands moving a ton Bell's Palsy -> one side of the face is droopy Gait test Wide base gait = arrhythmic steps that are wide and not syncrhonous antalgic gait = walking with your midline away from the center of the body tandem gait = where the toes of the back foot touch the heel of the front foot at each step.

HPI prior evaluation

If the patient has had any prior testing related to his complaint, it is important to document the following. Who ordered the test? (name and specialty) Specific name of the test Date of the test Results Diagnosis given to the patient

What is a chief complaint

It is the main reason that the patient was brought to the clinic. It is often one thing that made the patient come into the clinic. You always want to include a chief complaint and EVERY level of billing requires you to have it.

Physical exam findings -> neurological scores

Motor strength is out of 5 and symmetric or unsymmetric 5/5 = Normal strength 4/5 = Very mildly weak 3/5 = unable to overcome resistance 2/5 = unable to overcome gravity 1/5 = slight contraction, no movement 0/5 = flaccid, limp DTR's 2+ throughout 0 = absent 1+ hypoactive 2+ normal 3+ increased 4+ un-sustained clonus = continual movement or rhythm

Physical exam findings -> Perfusion

Normal -> Pulses Equal and Symmetric, Normal Capillary Refill Abnormal -> Delayed Capillary Refill -> if you put your finger on your thumbnail and press down you can see that the blood returns back to the area within 2 seconds. If it takes long for the finger to return to the normal color then you know that there is delay Carotid(carrotid), Radial, Femoral, Dorsalis Pedis and Posterior Tibialis (DP/PT) -> Dorsalis Pedis is the pulse found on the top of the foot and posterior tibialis is the pulse that is found behind the foot Pulse values 0 = absent 1+ = barely palpable 2+ = Easily Palpable (normal) 3+ = Full 4+ = Bounding/Aneurysmal (Aneurysm is an enlargement of an artery caused by artery wall weakness. Bounding is if the pulse is very strong and powerful, like a strong palpitations)

Physical exam findings -> Cardiovascular

Normal -> Regular Rate & Rhythm (RRR) Abnormal -> Tachycardia -> >100 BPM/ Brachycardia-> <60 BPM Irregularly Irregular Rhythm -> when there is no rhythm at all and the heart is beating out of control rapidly without a pattern. This is often due to Atrial Fibrillation (AFIB which is an irregular heart beat that can lead to problems in the heart) murmur -> put a number out of 6. These are turbulent sounds that you can hear during auscultation Extrasystoles -> These are extra heartbeats that you can hear Pleural rub -> Peridcardial friction rub gallop -> Heart rhythm that sounds like a horse galloping

Physical exam findings -> Eyes

Normal -> Pupils Equal, Round, Reactive to Light (PERRL) Extra Ocular Movements Intact (EOM) -> this means that the eyes can move along with the doctors finger Abnormal -> Scleral Icterus (icterus is jaundice). AKA you have a yellowing of the eye which is from a backup of bile from the liver Pale Conjunctiva -> pallor or very pale eyes Conjunctival Injection (eye that appears red due to illness or injury)

Physical exam findings -> General/Constitutional

Normal -> Alert, No Acute Distress (NAD)-> this means the patient is awake and present. They are alive and there if they are spacing or zoning out. They know what day it is and where they are. Abnormal -> Mild/Moderate/severe distress cachectic/emaciated/malnourished -> like elderly people or chemo patients that Somnolent -> difficult to wake up

Physical exam findings -> Pulmonary

Normal -> Breath sounds clear and equal Abnormal -> Mild/Moderate/Severe Respiratory Distress intubated -> When you have a device to force air into the patient lung Tachynpea (this is when you are breathing faster than normal) Accessory Muscle Use (This is when you are struggling to breathe and then you use other muscles in the area to help you do that) Diminished Breath Sounds (can't hear them breathing much) Wheezes, Rales (Crackles), Bronchi -> a clicking, rattling, or crackling sound that is typical of patients with Pneumonia or Bronchitis NC 02, CPAP, BiPAP, intubated -> Nasal Camula Oxygen 2 is something to document. CPAP AND BiPAP is when you force air into patient lungs intubated is to put a tube in somewhere to help a person breathe -> most likely for a breathing problem. Tracheostomy (trach) -> hole in trachea. This hole in the trachea is so that patients can breathe

Physical exam findings -> Head

Normal -> Normocephalic, Atraumatic NC/AT Abnormal -> Sinus Tenderness (this is when there is pain in the sinus) Angioedema -> Face swelling Hematoma -> collection of blood under the skin

Physical exam findings -> abdominal

Normal -> Soft and non-tender abnormal -> Mild/Moderate/Severe tenderness Voluntary/involuntary guarding -> voluntary guarding is when physician tries to touch you and then you go ahead and then guard against them by using your hands to stop them. Involuntary guarding is when your muscles go ahead and contract on their own when doctor touches you Rebound tenderness -> It hurts more to stop pushing than it actually does to push. So a palpation itself will not hurt but the letting go of it will hurt. Rigidity Distended -> bloated

Physical exam findings -> Neck

Normal -> Supple Abnormal -> Jugular Venous Distension (JVD) -> Here you can actually see the vein popping out and distending Carotid Bruit -> you can hear this in an when blood is rushing over a turbulent area Cervical adenopathy (Swollen Lymph Nodes) Midline Spinal Tenderness -> your actual spind is tender Paraspinal Tenderness -> The muscles around your spine are tender

Physical exam findings -> throat

Normal -> Oropharynx Normal, Moist Abnormal -> Dry Mucuous Membranes (DMM) Pharyngeal Erythema (Redness of throat) Tonsilar Exudate (See white spots on the tonsil) Peritonsilar Abscess (a collection of pus on the tonsils Dental Caries (Cavitites)

Physical exam findings -> neurological

Normal -> Alert and Oriented x 4 (A&O x4) -> do they know who they are, where they are, what time it is, and the even that they are at. Aka do you know what is going on around you non-focal neuro exam -> nothing is wrong with neurological aspects of the patient abnormal -> Sensation intact Motor strength 5/5 and equal -> can you resist the doctor pulling or do something with your muscles like a normal person DTR 2+ and Equal -> DTR is deep tendon reflexes, do they respond if you hit the kneecap? CN II-XII intact -> cranial nerve two - twelve intact Normal cerebellar exam Normal gait -> walking in a fashion that is different from normal by swinging side to side etc

Physical exam findings -> skin trauma

Normal -> Atraumatic Abnormal -> Ecchymosis is bruising so it is in the process of being bruised contusion is a bruise that has already formed. ecchymotic is bruised abrasion is a scratch lacteration is a cut (size in cm) Skin tear is when there is a tear of the skin Avulsion is when there is an eruption of skin. The skin is shredded

Physical exam findings -> skin infection

Normal -> No erythema, warmth, or drainage(aka any fluid removal from the body). Or wound/incision site is clean, dry, and intact abnormal -> erythema increased warmth induration (cellulitis) this is a skin infection -> red, tender, warm, swollen skin Fluctuance (abscess) which is pus trapped under the skin Purulent drainage -> abscess is full of pus and leaking

Physical exam findings -> Abdominal detailed

Normal -> Normal Bowel Sounds, No Organomegaly, no Mass Abnormal -> Bowel sounds are absent/hypoactive or hyperactive Organomegaly -> organs are enlarged. Hepatomegaly -> enlargement of the liver while Splenolmegaly -> enlargement of the spleen Distended -> again that is enlarged or bloated Murphy's sign -> an exam the physician does to differentiate pain in the upper right quadrant McBurney's pont tenderness -> test the right side of the abdomen and usually tells that there is appendicitis Colostomy, surgical drain, gastrostomy tube (G-tube) -> colon is rerouted to an opening so that waste will not go through an affected area of the colon and instead come out from another direction

Physical exam findings -> Nose

Normal -> Normal Nares (nostrils, singular: naris) Abnormal -> Epistaxis (Bleeding from the nostril) Rhinorrhea (Runny nose) Septal Hematoma (Swelling of the septum with blood) NG Tube (tube from nose to stomach for nutritional support or for decompression of stomach)

Physical exam findings -> Internal Ears

Normal -> Tympanic Membrane (TM's) Normal Abnormal -> TM Erythema (again redness that is in the area from dilated blood vessels) TM Bulging -> TM wont be flat and bulge outwards TM Dullness -> color of TM is white TM Obscured by Cerumen (Earwax)

Physical exam findings -> Skin

Normal -> Warm, Dry, Normal color Pallor Cyanosis (blue because no oxygen in the area) Jaundice -> yellowing because there is a problem with the liver Diaphoresis -> excessive sweating Petechiae -> polka dot rashes

Psychiatric

Normal = normal affect abnormal = flat affect -> flat emotion. Nothing in the voice just flat Suicidal ideation (SI) this is when you have thought about killing yourself but not the method -> This is different from suicidal plan because here you already have the idea on how to kill yourself Homicidal ideation -> thought of killing others but not the exact way Auditory Hallucination Visual Hallucination Flight of Idea -> having conversation topics that do not flow well. There is not much in common in the thread but it still works out. Tangential Pressured Speech Manic

HPI complaint focus

OLDCARS is the acronym to remember Onset -> when did the complaint begin? Location -> where is the discomfort that you are having. Duration -> How long does an episode last Characteristics -> do you feel any sharp pain, dullness, aching, cramping? Aggravating and Alleviating factors -> what makes it better? What makes it worse? Radiation -> Does the pain radiate anywhere else? Severity -> Rate the pain on a scale of 1-10

Objective

Objective information comes directly from us, the healthcare providers. This is what the healthcare provider observed, saw, heard, felt, or smelled. Or this can be a diagnostic test (vocal signs, labs, or imaging). Objective information includes vital signs, physical exam, tests, and results

Key difference

Palpitations are when your heart is beating very fast and it sounds like a huge bump. Palpations are when you are touching a patient to examine them by pressing down on them

HPI Pt vs Scribe

Pt/scribe I took Tums and it didn't help/ symptoms were unchanged by tums I have low back pain, but I always have that/ He notes chronic lower back pain, unchanged from base line. It hurts when I touch it/symptoms are worsened by palpations of the area Nothing makes it better or worse/ no aggravating or alleviating factors My sister has the same cold/ positive sick contact with sister who has similar symptoms If I try to eat or drink anything, I throw it back up/ vomiting is exacerbated by PO (Per Oral so just anything you take in your mouth) intake. It feels like a fizzing soda in the middle of my chest/ he describes symptoms as "a fizzing soda" in his central chest *put " if there are any sources of confusion on what the patient is trying to say

HPI Phrasing

Remember that the HPI is the STORY and CONTEXT of the patient's chief complaint. The general guidelines always apply -> write in complete sentences. Use proper capitalization and punctuation. Always check your spelling. Only used approved medical abbreviations. When in doubt just write it out. Dont/Do Do not use the days of the week for onset -> example it started monday/Count the number of days since the symptoms started. For example -> Sx(symptoms) began three days ago Do not use the word got as in got better or worse/ use phrasing like the symptoms became worse or symptoms worsened Do not start each sentence with the same phrase like Pt states again and again/ vary the beginning of your sentences. Just drop Pt states and start sentence with the next word Do not document self diagnoses -> like I have the flu of I have cancer/Say patient notes runny nose and vomiting Do not include PMHx, PSHx, or SHx that is not relevant to today's visit. Document only medical histories, surgeries, or social habits that are relevant to the current evaluation

What to put in the Subjective portion of the S.O.A.P notes.

Remember the key thing is that the subjective is something that is going to directly come from the person giving the history. In most cases, this is the patient or it could be someone accompanying the patient. This is the first thing that the physician discusses with the patient upon entering the room and the first part of the chart. Here you want to put chief complaint -> the reason for the visit. HPI -> the story of a chief complaint. ROS -> A checklist of symptoms from all body systems

7 regions of abdomen

Right upper quadrant, Left Lower Quadrant, Right Lower Quadrant, Left Lower Quadrant, epigastric region, periumbillical region, pelvic region

Chief Complaint Billing

Some chief complaints are non-reimbursable which means that you will not get money for the patient visit. Thus we need to fix non-reimbursable chief complaints into reimbursable chief complaints. Check-up -> 3 month diabetes management visit Follow-up -> HTN (hypertension) management evaluation Lab Results -> Discuss treatment options for elevated TSH (Thyroid Stimulating Hormone) Medication Refill -> Evaluation of medication management for HTN

S.O.A.P

Stands for Subjective, Objective, Assessment, and Plan

S.O.A.P Note Structure

Subjective -> Information from the patient. This includes Chief Complaint, HPI, ROS, and past patient history (Like SHx, FHx, PMSHx) Objective -> Information from the provider. This includes things like vital signs, Physical exam, orders, results Assessment -> the patient's diagnoses. This is where you write a short description of progress since the last visit. Plan -> Follow-up and treatment plan for each diagnosis

Essential S.O.A.P Vocab

Subjective -> this is what the patient is feeling. The HPI(History of patient illness is the story of the patient's chief complain) and ROS(Review of Systems is the head to toe checklist of patient symptoms) Objective -> factual information from the provider. The PE is the physical evaluation Intermittent -> Comes and goes. An example would be that you have back pain that happens when you are walking up the stairs. Sometimes you feel it when you walk up the stairs but sometimes you dont. Waxing and Waning -> this is when something is always present but changing in intensity -> for example if you walk up the stairs you feel some pain and if you run around you feel much more pain or if you sit down you feel some pain. The key here is that you are feeling some kind of pain at all times. Modifying factor -> Something that makes a symptom better or worse. Exacerbate -> this makes symptoms worse

ROS

The review of systems is a head-to-toe checklist of the patient's body symptoms ROS is phrased as a simple list of positives and negatives. It includes all symptoms the patient mentioned in the HPI. There is no story or context that is placed in the ROS. The ROS must never contradict the HPI since they are both subjective.

History of patient illness

The story of symptoms and events that led to the clinic visit (if the patient has a current complaint) belongs at the beginning of the chart immediately following the chief complaint. It essentially summarizes the reason for the visit -> this is the most common way to write a clinic HPI

Vital signs

There are 6 vital signs Blood pressure (BP) Respiratory Rate (RR) Heart Rate (HR) Pulse oxygen Temperature Weight

Physical exam findings -> rectal

You step outside of the room Normal -> Normal Rectal Exam, Heme Negative Abnormal -> Heme positive (Guaiac Positive) so there is blood in the stool. abnormal stool color -> Melena (black). Hematochezia (Red) Hemorrhoids -> Swollen and inflamed veins in the rectum and anus Decreased rectal tone -> dont have the ability to contract sphincter so there is loss of control in fecal movement Rectal prolapse -> large intestine slips out of the anus

Physical exam findings -> male genital

You step outside of the room Normal -> Normal genital exam note Circumcised/uncircumscised Testicular tenderness Epididymal tenderness testicular edema urethral discharge

Physical exam findings -> Female genital

You step outside of the room Normal -> Normal External, Bimanual, and Speculum Exam Abnormal -> Cervical motion tenderness Adnexal Tenderness or mass Uterine Tenderness Cervical OS Open Document that a female chaperon is present

HPI content

Your goal is to capture the answer to every question that the doctor asks. You don't have to write everything the patient says but ALWAYS write the answers to the doctor's specific questions. Each question is asked to raise or lower the suspicion of a particular disease which helps the doctor decide what tests to order. If the your chart is missing the answer to a question then the doctor has no record that you have ever asked it. EVERY QUESTION THAT THE DOCTORS ASKS IS VERY IMPORTANT

Physical exam findings -> Musculoskeletal/Estremitites

normal -> Non-Tender, Normal ROM, No Edema, Normal Tone Abnormal -> Bony Tenderness Tendon Laxity (loose tendon) Decreased ROM secondary pain -> pain so you cant have full range of motion Pitting Pedal Edema (trace to 4+) -> pitting is when you press edema and there is a pit that stays after some time. No pitting means edema does not sink in Calf Tenderness Palpable Cords/ Homan's Sign -> dorsiflexion test (Toes towards you) in order to test for deep vein thrombosis DVT

Physical exam findings -> External Ears

normal -> Normal Auricle/Pinna, Normal External Auditory Canal abnormal -> Pain with traction of the auricle/pinna or tragus canal erythema (erythema is reddening of the skin usually in patches that is superficial. So canal erythema is when there is redness in your canal) canal edema (When there is a lot of fluid build up in your ear) debris in canal (something that isn't supposed to be in your ears is there)

Physical exam findings -> back

normal -> Non-Tender Thoracic and Lumbar spine abnormal -> CVA tenderness -> Costovertebral angle tenderness -> so pain tenderness in the back that happens often in kidney infections (NOTE CVA ALSO REFERS TO A STROKE. THUS THIS IS WITHIN CONTEXT) paraspinal tenderness Vertebral Point Tenderness -> tenderness in any of the vertebrae -> cervical, thoracic, lumbar Midline deformities/step-offs Straight leg raise (Pain with right SLR (straight leg raise) at 60 degrees)