History Intakes and SOAP notes (1).pptx

History intake and SOAP note

1. z Overview of Medical Interviewing and Charting: Introduction to History Intakes and SOAP notes Megan Golani, ND Clinic Education Block

2. Patient-Centered Interviewing

3. z Patient-Centered Interviewing

4. Basic Principles in Charting The medical record is a legal document The chart can be seen by: The patient The doctor and those on “ need to know ” basis (this means you at the NUNM clinic) Other providers at your request or patient request Insurance companies providing coverage Lawyers in the case of lawsuits

5. Basic Principles in Charting Handwritten charts: Write legibly and spell correctly Write in black or blue ink only Never erase, white out or obliterate entries--draw single line through errors and initial it Do not skip lines, or squeezeextrawordsin Use conventional and approved abbreviations only

6. Basic Principles in Charting At the NUNM Clinics- each entry must be signed by the medical student and the supervising physician Each page should contain: Date of service Patient’s full legal name (can include preferred name) DOB (Date of Birth) Biological sex and Gender Page number

7. The SOAP Note Documentation method employed by healthcare providers to create a patient’s chart S= subjective O= objective A= Assessment P= Plan

8. “ Subjective ”

9. “ Subjective ” Chief Complaint (CC) History of present illness (HPI) Past medical history (PMH) Includes medications, allergies, surgeries, etc. Social history (SH) Includes diet, exercise, habits, occupation, sexual history, etc …. Family history (FH) Review of systems (ROS) A deeper look into other patient (pt) symptoms (sxs) that help rule your differential diagnosis (ddx’s) in/out

10. “ Objective ”

11. “Objective” Vitals- Height, weight Temperature - PO/PR/Axillary? Respiratory Rate Pulse rate – Regular or not? Blood pressure – Right or Left arm/leg, sitting/standing/lying O2 Sat%– not always included, but don ’ t forget about it when indicated

12. “Objective” Physical examination The rule of charting is.... If you didn’t chart it, you didn’t do it! Don’t forget your pertinent negatives! Throat WNL= Not enough info Pharynx non-erythematous, no cobblestoning, no exudate, tonsils +1 bilaterally Lab work- highlights only

13. “ Assessment ” or “Impression”

14. DDX in the Assessment A differential diagnosis is a list of other possible diagnoses- as a general rule don ’ t chart this unless you are ruling it out! If you are ruling it out- it probably goes in “ P ” - i.e. thyroid function tests ordered to rule out hyperthyroidism.

15. “Assessment” 58 yo male PTC with DM II (E11.9), poorly controlled x 2 years without medication. Given patient’s mildly elevated HbA1c but lack of symptoms and comorbidities and high level of motivation, the patient is a good candidate for nutritional and herbal therapies at this time. 33 yo G1P0A1 PTC with amenorrhea (N91.1) x 7 months with pregnancy ruled out via home urine test x 2. Strongly suspect PCOS based on hyperandrogen symptoms.

16. “ Plan ” Anything you did today or plan to do in the future. Treatments Labs performed in office or ordered Follow-up plans PARQ- (Procedures, Alternatives, Risks, Questions)

17. Basic Principles of the Medical Interview

18. Basic Principles of the Medical Interview

19. Starting the Interview

20. Starting the Interview Initial question: open ended, general No single best way to follow up, but there are several helpful mnemonics for the HPI OPQRST OLD CARTS LOCATES And others …. Always avoid medical terminology

21. History of Present Illness Duration – how long has the problem been going on? Is it similar to a past problem? What was done previously? Severity/Character – How bothersome is it? Does it affect daily activities? Can it be rated on a 1-10 scale? If the sx is pain, ask them to describe it in terms with which they are familiar. Location/Radiation – Is the sx located in a certain place? Is the pain focal or does it move or extend to another area?

22. History of Present Illness Have they tried any therapies? If so, does anything make it better? Worse? Pace of illness – Is the problem getting worse, better, or staying the same? If changing, what has been the rate of change? Associated symptoms – have there been any other symptoms that have come up at the same time as the main concern?

23. History of Present Illness What does the patient think is going on or what are they worried it might be? Why did you come in today? This is often relevant with long-standing issues

24. History-taking Mnemonics OPQRST: Onset, Provoking factors/Pain, Quality, Radiation/location, Severity, Timing OLD CARTS: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity LOCATES: Location, Onset, Character, Aggravating/Alleviating factors, Timing, Environment/setting, Severity