The Problem-Focused History & SOAP Note

Vocabulary-style flashcards covering SOAP notes, HPI, OLDCARTS, ROS, and related history-taking concepts from the lecture notes.

SOAP Note

A four-part clinical document: Subjective, Objective, Assessment, and Plan.

Subjective (S)

Data the patient reports: symptoms, feelings, concerns; collected during history.

Objective (O)

Findings observed by the clinician: signs, exam findings, labs, imaging.

Assessment (A)

The clinician’s diagnostic impression or list of possible diagnoses, ranked.

Plan (P)

The recommended management: treatments, tests, referrals, and patient education.

Factors impacting note taking

patient needs and concerns, goal of meeting/encounter/visit, the clinical setting

HPI (History of Present Illness)

Summary of chief complaint with specific details obtained via OLDCARTS, associated symptoms, and history of prior episodes.

OLDCARTS

A mnemonic guiding HPI questions: Onset, Location, Duration, Character, Aggravating factors, Alleviating factors, Radiation, Timing, Treatments tried, Severity, Setting.

Onset

When the symptom began; helps distinguish acute vs chronic.

Location

Where the symptom is felt; helps localize. For pain: point to location.

Duration

How long the symptom has been present, including timing (constant, intermittent).

Character

Quality or description of the symptom (e.g., sharp, dull, burning).

Aggravating factors

What makes the symptom worse (movement, activity, foods, etc.).

Alleviating factors

What makes the symptom better (rest, medications, position).

Radiation

Spread of pain to another location (e.g., to arm or jaw).

Timing

Pattern over time: onset, duration, frequency.

Treatments tried

Any medications, therapies, or interventions patient has already tried.

Severity

Intensity of the symptom (could be pain or impact on daily life), often on a 0–10 scale.

Setting

Context in which the symptom began (what the patient was doing).

What information to gather after OLDCARTS

associated symptoms and prior similar episode

Associated Symptoms

Mini-ROS; additional symptoms related to the CC gathered after OLDCARTS; allows findings of pertinent positives and pertinent negatives

Prior Similar Episode

Has this happened before; helps reveal chronic conditions.

HPI documentation

use the information gathered from OLDCARTS and document in paragraph form

Pertinent Positives

responses that support a working diagnosis.

Pertinent Negatives

responses that argue against a working diagnosis.

ROS (Review of Systems)

A subjective inventory of symptoms by body system; helps uncover data; subjective.

Comprehensive Health History

All elements of history and physical exam collected for establishing care or specialist referral

Problem-Focused Health History

Focused history for a specific problem; may address 1–2 concerns per visit.

Chief Complaint (CC)

The primary reason for the visit; usually a concise symptom.

Differential Diagnosis (DDx)

List of plausible conditions to consider, to be narrowed with data.

Sign

An objective finding observed by the clinician.

Symptom

A subjective experience reported by the patient.

Focused ROS

ROS tailored to the CC; questions chosen to focus on relevant systems; nearby systems (one above and one below)