Medical History I & SOAP Note Writing

Vocabulary flashcards covering key terms and concepts from the lecture on medical history taking and SOAP note writing.

Comprehensive History

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

Problem-Focused History

A shorter, specific patient history limited to the presenting problem or follow-up of chronic issues.

Chief Complaint (CC)

The main reason the patient is seeking care, recorded briefly in the patient’s own words.

History of Present Illness (HPI)

An expanded, structured narrative that explores the chief complaint using standard questions to narrow the differential diagnosis.

Past Medical History (PMH)

Record of a patient’s previous and current diagnoses, surgeries, hospitalizations, injuries, immunizations, and screening tests.

Medications

All prescription, over-the-counter, and supplemental products a patient takes, documented with exact dose and frequency.

Allergies

Adverse immunologic reactions to medications, foods, or environmental factors, always documented with the specific reaction.

Social History (SH)

Information about a patient’s lifestyle, relationships, occupation, habits, and exposures that can affect health.

Family History (FH)

Health information about close relatives, including ages, chronic diseases, and causes of death.

Review of Systems (ROS)

A systematic inventory of symptoms organized by body system to uncover additional problems.

Social Determinants of Health (SDOH)

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

SOAP Note

Structured clinical documentation format consisting of Subjective, Objective, Assessment, and Plan sections.

Subjective Section

Part of the SOAP note that contains information reported by the patient, including CC, HPI, PMH, meds, allergies, SH, FH, ROS, and SDOH.

Objective Section

Part of the SOAP note that records measurable findings such as vital signs, physical-exam findings, and test results.

Assessment Section

Part of the SOAP note listing the differential diagnoses, problem list, somatic dysfunctions, and pertinent SDOH.

Plan Section

Part of the SOAP note detailing diagnostic tests, treatments, OMT, patient education, and follow-up arrangements.

Sign

An objective clinical finding observed by the examiner.

Symptom

A subjective experience reported by the patient.

Differential Diagnosis (DDx)

A ranked list of plausible conditions that could account for the patient’s presentation.

Problem List

A compilation of current and chronic issues that require ongoing management.

Somatic Dysfunction

Impaired or altered function of related components of the somatic (body framework) system addressed in osteopathic diagnosis.

Vital Signs

Basic physiologic measurements: temperature, pulse, respiration, blood pressure, and oxygen saturation.

Mnemonic OLD CARTS

Aide-mémoire for HPI questions: Onset, Location, Duration, Character, Aggravating/Alleviating/Associated symptoms, Radiation, Timing, Severity.

Mnemonic OPPQRST & AS

Aide-mémoire for HPI questions: Onset, Provokes, Palliates, Quality, Radiation, Severity, Timing & Duration, Associated Symptoms.

Open-Ended Question

A broad query that allows the patient to describe symptoms in their own words.

Forced-Choice Question

A query that gives the patient limited options (e.g., sharp or dull) to clarify details.

Directed Question

A yes/no question aimed at confirming a specific symptom or detail.

Comprehensive Physical Exam

An extensive examination of all body systems usually performed with a comprehensive history.

Problem-Focused Physical Exam

A targeted examination limited to body areas related to the chief complaint.

Active Listening

Communication skill involving attentive, empathetic listening during history taking.

NKDA

Medical abbreviation meaning No Known Drug Allergies.

HTN

Medical abbreviation for Hypertension.

DM

Medical abbreviation for Diabetes Mellitus.

OMT

Osteopathic Manipulative Treatment—manual techniques used to treat somatic dysfunction.

CTA (lungs)

Medical abbreviation for Clear To Auscultation, indicating normal lung sounds.

Poverty (SDOH)

Income below the federal poverty line leading to unmet basic needs such as nutrition, clothing, and shelter.

Food Insecurity

Lack of reliable access to affordable, nutritious food.

Unstable Housing

Living situation without permanent, safe residence, including homelessness or frequent moves.

Health Literacy Limitation

Difficulty obtaining, processing, or understanding health information needed to make appropriate decisions.

Transportation Issues

Barriers to accessing healthcare due to lack of reliable or affordable transport.

Accuracy Principle

Documentation rule stating that if information is not written, it is legally considered not to have been done.

Standard Abbreviations

Common, accepted shorthand used in medical notes to save time and space; non-standard abbreviations should be avoided.

“Not Documented = Not Done”

Legal and professional maxim emphasizing the necessity of thorough clinical documentation.