Soap Note

Question 1

How do you document PE?

Answer 1

• be very specific
• was it b/l or u/l?
• put everything you did, saw, and identified in the room (regardless of outcome)

Question 2

Components of vascular assessment

Answer 2

• pulses
• edema
• capillary refill

Question 3

OSE

Answer 3

• OSE is an OBJECTIVE FINDING
• Must include three of four tart findings to meet guidelines for billing
• Tenderness (pt comment)
• Asymmetry
• Restrictions in motion
• Subtle glides and functional joints motions NOT the same as orthopedic assessment
• Tissue texture changes

Question 4

What is the minimum to report with OSE?

Answer 4

SD and region –> go in assessment

Question 5

Where does FH MI go?

Answer 5

assessment

*note I said FH MI (not just FH, which would be a SUBJECTIVE account give by pt)

Question 6

What are the key points of pt hand off?

Answer 6

• Brief (generally ~ 5 minutes)
• Provides enough information to tell the audience how you came to your most likely dx
• Must be in chronologic order
• Must follow SOAP note format
• Accurately review the historical events that lead the patient to make the appointment
• Identification of risk factors and/or other underlying medical conditions that might affect the diagnosis
• Generate an assessment and plan

Question 7

What do you start with in objective section?

Answer 7

vital signs