Medical History I & SOAP Note Writing

Vocabulary flashcards summarizing essential terms, abbreviations, and concepts from the Medical History I and SOAP Note Writing lecture.

Comprehensive History

A detailed patient history aimed at complete knowledge of the patient’s health status; used for new patients, admissions, consultations, and annual physicals.

Problem Focused History

A shorter, specific history centered on a single problem or chronic-care follow-up visit.

Chief Complaint (CC)

The patient’s main reason for seeking care, documented briefly in the patient’s own words.

History of Present Illness (HPI)

Narrative expansion of the chief complaint that explores symptom details, context, and associated factors.

Past Medical History (PMH)

Record of current and past illnesses, surgeries, injuries, hospitalizations, immunizations, and screening tests.

Medications

List of prescription, OTC, and supplement drugs including dose and frequency.

Allergies

Documented adverse reactions to drugs, foods, or environmental exposures, including the specific reaction.

Social History (SH)

Information on relationships, occupation, lifestyle habits, substance use, safety, and other social factors.

Family History (FH)

Health information about immediate and extended relatives, including ages and causes of death.

Review of Systems (ROS)

System-by-system checklist of symptoms to uncover additional problems.

Social Determinants of Health (SDOH)

Non-medical factors such as housing, income, education, and transportation that influence health outcomes.

SOAP Note

Structured clinical documentation divided into Subjective, Objective, Assessment, and Plan sections.

Subjective (SOAP)

Information supplied by the patient, including CC, HPI, PMH, meds, allergies, SH, FH, ROS, and SDOH.

Objective (SOAP)

Clinician-observed data such as vital signs, physical exam findings, and test results.

Assessment (SOAP)

Clinician’s diagnoses, differential diagnoses, problem list, somatic dysfunctions, and noted SDOH.

Plan (SOAP)

Proposed tests, treatments, OMT, patient education, and follow-up instructions.

Sign

Objective finding detectable by the examiner (e.g., fever, rash, murmur).

Symptom

Subjective sensation reported by the patient (e.g., pain, nausea).

OLD CARTS

Mnemonic for HPI questions: Onset, Location, Duration, Character, Aggravating/Alleviating/Associated, Radiation, Timing, Severity.

OPPQRST & AS

Expanded HPI mnemonic: Onset, Provokes, Palliates, Quality, Radiation, Severity, Timing/Duration, Associated Symptoms.

Open-Ended Question

Broad inquiry allowing the patient to describe symptoms freely (e.g., “Can you describe the pain?”).

Forced-Choice Question

Question offering limited options (e.g., “Is the pain sharp or dull?”).

Directed Question

Yes/No or very specific inquiry (e.g., “Is the pain sharp?”).

Differential Diagnosis (DDx)

Ranked list of plausible disorders explaining the chief complaint.

Problem List

Compilation of chronic and acute issues requiring management beyond the current complaint.

Format (History/Note)

The organized written or verbal structure—chronological or outline—of the medical record.

Process (History-Taking)

The conversational method relying on communication skills, active listening, and empathy.

Somatic Dysfunction

Impaired or altered function of related components of the body framework, documented in osteopathic assessment.

Osteopathic Manipulative Treatment (OMT)

Manual therapy techniques used by DOs to treat somatic dysfunctions.

Vital Signs

Objective measurements including temperature, pulse, respiration, blood pressure, and oxygen saturation.

PRAPARE

Screening tool recommended for identifying patients’ Social Determinants of Health.

Poverty (SDOH)

Income below the poverty line leading to unmet basic needs and health barriers.

Food Insecurity

Unreliable access to adequate, nutritious food, often in food deserts.

Unstable Housing

Lack of permanent, safe residence; homelessness or poor-quality housing.

Health Literacy Limitation

Difficulty obtaining, processing, and understanding health information needed for decisions.

Sign-Off (SOAP Note)

Clinician’s dated signature verifying accuracy and authorizing orders.

“Not Documented, Not Done”

Medical-legal principle that undocumented care is legally considered not provided.

Common Abbreviation: NKA

No Known Allergies—used in the Allergy section of a note.

Common Abbreviation: WNL

Within Normal Limits—indicates normal findings on exam or labs.

Common Abbreviation: CTA

Clear To Auscultation—normal lung exam finding.