Clinical Medicine Lecture #1 – Taking a Good Medical History & Writing the SOAP Note

Flashcards covering grading rules, SOAP structure, history components, key mnemonics (OPQRST, MYCASST, CDEFG, THE O CHADS, MOTHRRS), ROS essentials, documentation pitfalls, and professionalism points from Dr. Crosbie’s lecture on taking a good medical history.

In the SOAP format, what does the S stand for and what belongs there?

Subjective – everything the patient tells you: HPI and medical history

In the SOAP format, what does the O stand for and what belongs there?

Objective – things you observe or measure: vitals, physical-exam findings, labs, imaging.

In the SOAP format, what does the A stand for?

Assessment – a succinct, prioritized list of problems addressed during the encounter.

In the SOAP format, what does the P stand for?

Plan – the detailed strategy for each assessed problem (treatment, testing, follow-up, etc.).

What are the components of a complete history?

The components of a complete history include the

chief complaint,

history of present illness (HPI),

review of symptoms (ROS),

past medical history (PMH),

past surgical history (PSH),

medications,

allergies,

social history,

family history.

Define the Chief Complaint (CC).

A 2-5-word quoted phrase explaining why the patient is seeking care; required for billing and OSCEs.

Which mnemonic is used for acute problems in the HPI?

OPQRST and A (expanded to OPPPPQQRRsSSTTTA).

What does OPQRST and A stand for

Onset

prior

progression

provoke

palliate

quality

quantity

radiation

scale

severity

sick contacts

timing

treatment

trauma

associated symptoms

What mnemonic is recommended for chronic problems in the HPI?

MYCASST.

What does MYCASST stand for?

Medications

years

control

appointment

specialists

satisfaction

testing

Which mnemonic is used for health-maintenance visits?

CDEFG (actually CCDDDEFFFG).

What does CDEFG stand for?

Colonoscopy

cholesterol

DEXA scan

dentist

digital rectal

eye exam

flu shot and other vaccines

female exams

fall risk

glucose

When is a FULL Review of Systems (ROS) required?

For new patients and healthy patients having physicals or pre-ops.

What are the three major rules stressed about the ROS?

1) It must be a separate section, 2) Review of Systems, not Symptoms, 3) Never write “See HPI.”

What mnemonic helps recall common Past Medical History conditions?

THE O CHADS

What does THE O CHADS stand for?

Thyroid,

HTN,

Emphysema/COPD,

Obstructive sleep apnea,

Cancer,

Heart disease,

Asthma,

Diabetes,

Stroke

What basic details must be documented for every medication?

Name, strength, frequency, number of tabs, route, last dose, side effects, length of time on medication.

What are the elements of a Social History?

Nicotine use, alcohol intake, caffeine, diet, exercise, recreational drug use, cultural/religious factors, occupation, relationship status, sexual orientation, travel, military service, hazardous exposure.

Is it acceptable to list only a symptom in the Assessment if no diagnosis is known?

Yes; e.g., “Headache” can be an assessment item when etiology is uncertain.

Which mnemonic structures a comprehensive Plan?

MOTHRRS.

What does MOTHRRS stand for?

Medicines

osteopathic

testing

holistic

referral

return

self care

Why should lab or imaging results appear in both the HPI and Objective sections?

They may be contextually relevant in the HPI but must also be listed objectively in their own section.

What question about severity may provide better clinical information than the 1–10 pain scale?

“What is this problem preventing you from doing?”