Академический Документы
Профессиональный Документы
Культура Документы
Objectives
Review useful mnemonics Review SOAP note writing Demonstrate Ideal SOAP notes Discuss SP checklists Display a sample Grading Rubric
Useful Mnemonics
S = Summarize
Useful Mnemonics
COPMAPS can be used in all history taking encounters. Other mnemonics should be used if relevant to the specific case. You will not be counted off for not using a mnemonic, but you will be expected to have obtained all of the necessary information- which is sometimes easier to gather if you use a mnemonic.
SOAP Notes
The Basics
S = Subjective Data O = Objective Data A = Assessment P = Plan
Subjective = History
Identifying data Chief complaint in chronological order start with the most current episode History of the present illness/chief complaint COPMAPS include pertinent positive AND negative reports
Subjective = History
Pertinent other is an area often overlooked Should consist of PMH, Surg Hx, Meds,
Allergies (specifically medication; food and environmental if may be pertinent), Fam Hx, Soc Hx as relevant to the chief complaint or as necessary documentation for a new patient Caution: If you do not ask, you may not know if an item is relevant or not!
Subjective = History
May include information from others & reported test results Use only approved abbreviations Needs to be readable, i.e., make sense to the reader Need to mark errors with single line, initial, and date
Plan
Includes: Treatments (preventive, therapeutic, medication additions/ cancellations/ dose changes) Diagnostic evaluations (lab, XRs, consults) Patient education Follow-up instructions (must have!) Needs to correlate with your assessment
SP Checklists
SP Checklists
Standardized patients score students on: History taking skills Physical exam skills OMM skills Patient centered care
Respectful of patient; assisted patient when needed
Communication
Verbal and nonverbal considered
Grading Rubric
Grading Rubric
SOAP notes are graded by faculty
Most often by the faculty member who wrote the case.
There may be some variation of points within a section due to differences in important points of cases.