SOAP

Ways a patient can arrive at the ER

By ambulance or personal vehicle.!!

First step after patient arrives at the ER

Patient is registered and triaged.!!

Who determines how quickly a patient should be seen

The triage nurse.!!

What happens during the evaluation step in the ER

The provider asks questions and performs a physical exam.!!

Tests or treatments that may be ordered in the ER

Labs, imaging, and medications.!!

Two possible outcomes after ER evaluation

Patient is either admitted to the hospital or discharged home.!!

What does SOAP stand for

Subjective, Objective, Assessment, Plan.!!

What is included in the "Subjective" section of a SOAP note

Information from the patient or family (symptoms and history).!!

What is documented in the "Objective" section

Measurable information like vital signs, physical exam findings, and test results.!!

What does the "Assessment" section include

Diagnoses.!!

What does the "Plan" section detail

Next steps in care: admit, discharge, meds, or follow-up.!!

What is the Chief Complaint (CC)

A 2–3 word summary of why the patient came to the ER.!!

What does HPI stand for

History of Present Illness.!!

What does the HPI describe

A detailed story of what led the patient to the ER.!!

Acronym used to organize the HPI

COLD CARS.!!

What does COLD CARS stand for

Context, Onset, Location/Radiation, Duration, Character, Alleviating/Aggravating factors, Related symptoms, Severity.!!

What does PMHx stand for

Past Medical History.!!

What does PSHx stand for

Past Surgical History.!!

What does SHx stand for and include

Social History – drug/alcohol use and living situation.!!

What does FHx stand for and include

Family History – genetic conditions in first-degree relatives.!!

What is the Review of Systems (ROS)

Checklist of yes/no questions about symptoms by body system.!!

What is the Physical Exam (PEx)

Direct observations made by the provider, organized by body system.!!

What types of tests are included in Labs and Radiology

CBC, CMP, X-ray, CT, MRI, and ultrasound.!!

What is included in Medical Decision Making (MDM)

Differential diagnoses (DDx), final diagnosis with reasoning, response to treatment.!!