Clinical Med-SOAP note

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S= O= A= P=
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Subjective Objective Assessment Plan
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CODIERS
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Chronology Onset Duration Intensity Exacerbation Remitting Symptoms associated
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1. chronology
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-Have you had this before -When did you have it -How many times -What did you do for it -Did you see a physician -What did they do -Did that work well
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2. onset
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-when did it start? -what were you doing?
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3. duration
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-how long does it last? -has it changed?
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4. intensity
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how bad is it?
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5. exacerbation
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what makes it worse?
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6. remission
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-what makes it better -what drugs make it better?
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7. symptoms associated
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-do you have any ____ symptoms
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What do you need to know about this patient’s medical history?
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SMASH FM
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SMASH FM
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-surgical history -medical history -allergies -social history -hospitalization -family history -medications
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for the \”social history\” part of SMASH FM use the mnemonic…
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FED TACOS
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FED TACOS
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-food/diet -exercise -drugs -tobacco -alcohol -caffeine -occupation -sexual history
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for your \”plan\” as a doctor use this mnemonic
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MOTHRR
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MOTHRR
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-meds -OMM -tests -holistic/humanistic -referrals -return
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on the SOAP note always make sure you include…
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-date/time -patient’s name -medical record number -signature
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SOAP: S=subjective data is..
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-what the patient tells you -NOT responsible for making sure this is accurate
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CODIERS: S=symptoms associated
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-grouped as + and –
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SOAP: O=objective includes..
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-vital signs -physical exam -test results -record EVERYTHING you checked
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SOAP: A=assessment
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-differential diagnosis (primary diagnosis, secondary diagnosis, & what you doubt it is)
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SOAP: P=plan for primary diagnosis is going to include…
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MOTHRR (meds, OMM, tests, holistic, referrals, return)
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brief pre-op note
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-written day of surgery -gives a report of why they’re going to the OR
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brief operative note
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-written in chart immed. after surgery -tells physicians/nurses what happened in OR
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operative note
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-more detailed description of procedure -NOT med students resp.
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inpatient chart
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-hospital property -must be signed
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outpatient chart
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-kept on record for a specific amount of time
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CBC
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left=WBC top=Hbg right=platelets bottom=Hct

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