Compoments of A Clinical Note

SOAP

Four components of a clinical note

CC, HPI, PMH, FH, SH, ROS

What are the components of Subjective?

the primary reason the patient is seeking care. quote the patient when possible

What is the CC?

Introductory statement, OLD CARTS, Pertinent Positives and Negatives

What are the components of the HPI?

Childhood illnesses, Adult Medical Illnesses (current and/or chronic medical conditions), Surgical history, OBGYN History (females only), Psychiatric History, Preventative care/health maintenance (immunization and screening tests), Current medications (ensure matching condition), allergies (ensure reaction and severity are listed)

What are the components of Past Medical History?

Collect History on: parents, siblings, children, and grandparents. List the age and condition of each individual. If deceased, add age of death and cause. List familial trends.

What are the components of family history?

Marital status, occupation/education status, living arrangements, religion, personal interest, family origin, sexual orientation and habits. Tobacco, Alcohol, Recreational Drug use, Sexual History

What are the components of Social History?

weight gain or loss, orientation, activity level, fever, chills, fatigue, sweats

General

color change, pallor, rash, wound

Skin

change in hearing, vision, smell, or taste; pain or discomfort in ears, eyes, nose, throat, sinuses; persistent or uncharacteristic headaches, nasal discharge, change in voice

HEENT

swollen glands or other areas of swelling, restriction of movement

Neck

changes to skin or tissue (lumps)

Breasts

shortness of breath, cough, dyspnea on exertion, hemoptysis, orthopnea

Respiratory

chest pain with or without exertion, chest wall pain, venous changes, swelling of the feet and/or hands

Cardiovascular

change in appetite, difficulty chewing or swallowing, nausea, vomiting, diarrhea, constipation, cramping, bloating, indigestion, blood in stool, hemorrhoids

Gastrointestinal (GI)

pain with urination, hesitancy, frequency, hematuria

Urinary

irregular menses, painful menses, vaginal pain or discharge, dyspareunia, penile discharge, testicular or scrotal pain or swelling

Genital

range of motion joints, joint pain or swelling, redness or warmth of a joint

Musculoskeletal

depressive mood, anxiety, affective or personality disorders, sleep disturbances, suicidal thoughts or ideation, homicidal thoughts or ideation, hallucinations, delusions, substance abuse

Psychiatric

dizziness, facial asymmetry, headaches, numbness, seizures, speech difficulty, syncope, tremors, weakness

Neurologic

easy bruising, adenopathy, bleeding from the gums, delayed wound healing, recurrent infections

Hematologic

heat or cold intolerance, excessive thirst (polydipsia), excessive hunger (polyphagia)

Endocrine