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SOAP Notes and Cultural Competency
Focused Exam - Answer: ✅✅-Patient encounter where the "focus" is on the patient's chief complaint
-are documented in a SOAP NOTE
-SOAP notes are not complete History & Physicals
-perform this
-problem oriented
-only ask questions related to chief complaint
-what brings patient to this visit
S - Answer: ✅✅Anything the patient or family tell you
Chief Complaint & Duration
HPI- include SLIDTA
History-PMH, PSH, Medications, Allergies
Chief complaint:
HPI:
Significant PMH/PSH:
Allergies:
Medications:
Social: who do you live with, do you have significant other?
Smoking:
ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize CAGE) Do you drink alcohol? How much?
Living environment: (Ask If there is an area of concern)
- do you feel safe, are you afraid in your own home?
-ab pain we don't care about cataract surgery, not relevant
CAGE - Answer: ✅✅Cutting down, annoyance when asked about drinking, Guilt do you feel guilty about it, Eye opener - to get you going in the morning
-if response is 2/4 needs further evaluation
Chief Complaint - Answer: ✅✅Limited to one complaint, most pressing
Brief- as few words as possible
Duration always included
Example: Sore throat for 2 days
-why they are here
ex: fevers , chills, nausea (associated sx) but PAIN is the main thing, most important
-anyone who presents with painful urination always question STD/STI, ask about discharge, sexual activity, check back for CVA tenderness
ex: constipation, ear pain, otitis media, pharyngitis
-to determine the reason patient seeks care
-important to consider using the patient's terminology
-provides "title" for the encounter
-what brings you to the office? why did the symptom bring you to the office?
-describe it like you would to a relative or neighbor
History of Present Illness - Answer: ✅✅-Follows the Chief Complaint
-Always starts with: "This is a (age/race/sex)
-Narrative statement
-You ask the appropriate questions and record the patient's responses.
-You guide the patient to answer your questions.
-Include SLIDTA
-Difference between SOAP and H&P: associated symptoms go in body of HPI
-This is a 52 year old African American male who presents today with....
-If fever - always write temp max
-Patients' positive response to ROS is recorded as reports..........
Patients' negative response to ROS is recorded as denies.......
Omit: "he" "she" "patient" "patient states"
-Gather information in an orderly fashion to come to a diagnosis
-90% of the time the diagnosis is made by the end of the HPI (assuming that you have asked the correct questions)
-Learning how to ask the right questions is key
-Don't write "here" or "with complaints"
Severity and associated symptoms - to identify the symptom's severity (how bad at its worst) and any associated symptoms (presence or absence of nausea and vomiting associated with chest pain)
Timing and temporal descriptions - to identify when complaint was first noticed, how it has changed/progressed since onset (remained the same or worsened/improved); whether onset was acute or chronic; whether it has been constant, intermittent or recurrent
Differential Diagnoses - Answer: ✅✅-Once you have the information, you formulate these in your mind. This is what I am thinking this patient has
- hypotheses as to what illness(s) is the cause of the patients chief complaint.
-They are not written down at this point.
-When formulating these consider age and sex:
- 27 y/o male are going to be different than in a 27 y/o female
-Abdominal pain in a 22 y/o female will have these than a 62 y/o female with abdominal pain - 22 y/o could be pregnant, ectopic, date of last gyn exam, might perform or suggest they have one whereas 62 y/o could have obstruction or cancer
-Once you are done with the HPI, you rearrange the list of these in your mind, with the most likely one first.
-They are not written down, as you haven't examined the patient, these are your thoughts as to what the diagnosis could be
-Your physical exam is guided by these.
-Zero in once physical exam is done
-think could be the problem, but not sure
-throat pain: strep pharyngitis or viral pharyngitis - can't diagnose by looking at patient, but could be suspicious
-need to rule out, rule in
-listed below actual dx (what you really think the patient has)
-is based on an understanding of probability and prognosis
-this means that conditions considered are those that most commonly cause the perceived cluster of data (probability) as well as conditions that may be less common but would require urgent detection and action (prognosis)
-Times arise when a definitive these is not identified, yet urgent explanations have been ruled out.
-In these situations, options include moving forward with additional diagnostic measures, including further history, physical examination, diagnostic studies and/or referral or consultation.
-Another option involves waiting briefly before further diagnostic studies are performed in order to see whether or not the conditio
O - Answer: ✅✅-Objective data
-Vital signs, physical examination, diagnostic tests are all objective data.
-FOR EVERYONE
Vital signs
HT/WT/BMI
General Survey - your observations, haven't touched patient yet, gait steady appears in no distress, first part of physical examination
Auscultate the lungs
Auscultate the heart
Vital signs
Recent Labs: (with date of draw or EKG/UA/any diagnostics done that pt brings recently done)
General Survey:
Physical Exam:
Lung:
Heart:
(Other exams as indicated)
Physical Exam - Answer: ✅✅-The rest of the physical exam in a focused exam based on the patient's chief complaint, HPI and your differentials:
-Example: if the chief complaint is abdominal pain, perform a complete abdominal exam, but not a neuro exam(unrelated to chief complaint)
-Example: if the chief complaint is cough, perform a full respiratory exam, but not a musculoskeletal exam (unrelated to chief complaint)
-Head to toe
-Abdominal pain - heart, lungs, abdomen
-Neck pain - neck, heart, lungs
-Last gyn exam must be within 6 months for our class
Diagnostics - the American College of Radiology's Appropriateness Criteria provides guidlines on selecting imaging studies
Referrals - colonoscopy need to refer to GI
Patient education - be specific, no "drink lots of fluid" write "drink eight 8-10oz glasses of water per day)
Follow-up
Always start with meds that you are ordering for that patient
Start Augmentin, dosage, route, frequency and duration (X 10 days)
Don't write "continue all meds"
List out all medications that the patient was on
Continue Allopurinol
Continue Metformin
Continue Fish Oil
Labs - that you ordering, not ones that you have results from - results they bring in goes in objective section
Write rational for why you ordering lab
Diagnostics - None (if not ordering anything, don't leave blank) reference if order
Referral - for colonoscopy need to put referral to Gastroenterology
Patient Education - always education, medication, disease related, don't have to reference
Follow up - when do you want to see this patient again, 2 weeks, call office is symptoms worse, go to 911 if...
Most important to reference: assessment, meds, labs and diagnostics
- include references and rationale
Medications: (listed)
Labs: That you are ordering
Diagnostics: That you are ordering
Referral: (To whom are you referring, reason & how soon they should see provider)
Patient Education: bullet (Be specific & note if patient agrees w/ plan or not)
Follow Up
Return to Office: (Date or time frame)
Notify office: (If s/s worsen... upon completion of diagnostics...)
References (Three in APA format)
Past Medical History - Answer: ✅✅to identify past diagnoses, surgeries, hospitalizations, injuries, allergies, immunizations, current medications
Habits - Answer: ✅✅to describe any use of tobacco, alcohol, drugs and to identify any patterns of sleep, exercise etc
Sociocultural - Answer: ✅✅-to identify occupational and recreational activities and experiences, living environment, financial status/support as related to health-care needs, travel, lifestyle
Family History - Answer: ✅✅to identify potential sources of hereditary diseases
-a genogram is helpful
-the minimum includes first-degree relatives (parents, siblings, children) although second and third orders are helpful
Review of systems - Answer: ✅✅to review a list of possible symptoms that the patient may have noted in each of the body systems
Bayes's theorum - Answer: ✅✅-standard for basing a clinical decision on available evidence
-involves using knowledge of the pretest probability and the likelihood ratio to determine the probability that a particular condition exists
-can estimate posttest probability of a condition based on a population of patients with the same characteristics, product of pretest probability and likelihood ratio
-nomograms are available to assist
Sensitivity - Answer: ✅✅-the % of individual with the target condition who would have an abnormal or positive result
-bc a high this indicates that a greater % of persons with the given condition will have an abnormal results, a test with a high this can be used to rule out the condition for those who dont have an abnormal result
- Incorporates cultural preferences, health beliefs, behaviors, and traditional practices into the management plan
- Develops client appropriate educational materials that address the language and cultural beliefs of the client.
- Accesses culturally appropriate resources to deliver care to clients from other cultures
- Assists clients to access quality care within a dominant culture.
NONP Clinical Competency: Spiritual - Answer: ✅✅1. Respects the inherent worth and dignity of each person and the right to express spiritual beliefs as part of their humanity.
- Acknowledges personal biases and prevents these from interfering with the delivery of quality care to persons who hold differing religious and spiritual beliefs.
- Assists clients and families to meet their spiritual needs in the context of health and illness experiences, including referral for pastoral services
- Assesses the influence of clients' spirituality on their health care behaviors and practices.
- Incorporates clients' spiritual beliefs in the plan of care appropriately.
- Provides appropriate information and opportunity for clients and families to discuss their wishes for end of life decision-making and care.
Sense of Self and Space - Answer: ✅✅US: Informal, Handshake
Other: Formal, Hugs, bows, handshakes
Communication and Language - Answer: ✅✅US: Explicit, direct communication, Emphasis on content - meaning found in words
Other: Implicit, indirect communication, Emphasis on context - meaning found around words
Dress and Appearance - Answer: ✅✅US: "Dress for success" ideal, Wide range in accepted dress, More casual
Others: Dress seen as a sign of position, wealth, and prestige, Religious rules, More formal
Food and Eating Habits - Answer: ✅✅US: Eating as a necessity - fast food
Others: Dining as a social experience, Religious rules
Time and Time Consciousness - Answer: ✅✅US: Linear and exact time consciousness, Value on promptness, Time = money
Other: Elastic and relative time consciousness, Time spent on enjoyment of relationships
Relationship, Family and Friends - Answer: ✅✅US: Focus on nuclear family, Responsibility for self, Value on youth, age seen as handicap
Other: Focus on extended family, Loyalty and responsibility to family, Age given status and respect
Values and Norms - Answer: ✅✅US: Individual orientation, Independence, Preference for direct confrontation of conflict, Emphasis on task
Other: Group orientation Conformity Preference for harmony
Psych Evaluation - Answer: ✅✅- When a client presents with complaints of feeling tired, having difficulty sleeping, and feeling agitated and anxious, the practitioner must rule out a medical illness, determine whether the symptoms are in response to medications and explore whether they are related to a stressful life event. When these possibilities are ruled out, a psychiatric evaluation may be indicated.
- HPI: General analysis should explore the time line related to symptoms, the relationship of the symptoms to life events, any recent conflicts or stressors, any drugs that are used, and how the current level of functioning differs from the clients previous level of functioning
- If the patient indicates that the problem has existed for sometime, the sequence of events leading up to the visit at this particular time may identify important triggers that have either exacerbated the problem or convinced the patient that help was needed for the problem
Mental Status Exam - Answer: ✅✅five major areas 1) appearance and behavior, 2) mood and affect 3) speech and thought process 4) thought content and perceptual abnormalities 5) sensorial, cognitive and intellectual functioning
Appearance and Behavior - Answer: ✅✅gait, dress, grooming, posture, gestures and facial expressions, nutrition status, eye contact, unusual behaviors, mania - psychomotor agitation, distractibility, colorful clothes or bizarre combo, excessive makeup and intrusiveness
Mood and Affect - Answer: ✅✅ask client to describe how he or she feels: well, happy, depressed, anxious etc (mood is subjective experience as self-reported)
Affect is your impression - happy, depressed, anxious, flat, etc
Speech and Thought Process - Answer: ✅✅tone, quality, quantity, rate. Mania - pressured, loud, dramatic, exaggerated depression - soft, monotone with little or no spontaneity
Miscellaneous (sleep apnea, anemia, CHF)
Electrolyte abnormalities and toxins (K, Na, chemical exposures)
Drugs (also nicotine and caffeine)
Anxiety Disorders - Answer: ✅✅uncertainty and fearfulness, more common in women, chronic anxiety disorders can increase the rate of cardiovascular related mortality
Unpleasant feeling of apprehension, often accompanied by perspiration, palpitation, stomach discomfort, restlessness, difficulty sitting still, and even tightness in the chest, no specific focus, distinguished by the intensity duration level of impairment to coping it renders and if there is an environmental trigger
Fear - there is an identifiable dreaded object
-commonly present with somatic complaints - chest pain (with negative angiogram), irritable bowel, unexplained dizziness, migraine headache, and chronic fatigue
Most obvious indicators: increased heart rate, blood pressure, pallor, dry mouth, increased respiration, and sweating, fight or flight response - sympathetic
Parasympathetic - pacing, tapping toes or fingers, adjusting clothing (displacement activities
Children and adolescent - headache, stomach ache or excessive worry and fears
Meds that cause: caffeine, thyroid med, theophylline, albuterol
Panic Disorder - Answer: ✅✅recurrent unexpected panic attacks about which there is persistent concern, discrete epsiodes of intense anxiety that peak within 10 minutes and associated with autonomic arousal (cardiac, pulmonary, GI, and neuro symptoms) and feelings of depersonalization/de realization and they fear of dying, losing control, or going crazy
After initial attack, the apprehension of a future attack often occurs and is referred to as anticipatory anxiety, often as distressing (if not more so) than the experience of an actual episode
: Have you had episodes when you felt nervous, frightened, anxious or uneasy in situations when most people didn't feel that way? Did the feelings peak within 10 minutes?
Do you feel nervous in places when you might have a panic attack or when escape might be difficult, such as in a crowd; standing in a line; on a bridge; or in a bus, plane or train?
In the past did these episodes occur unexpectedly?
Was your heart racing?
Did you have difficulty breathing?
We're your hands sweaty?
Did you have chest pain?
Did you fear that you were dying?
Did you feel dizzy or thing you were going to faint?
Have you had an episode and then for a month or more feared having another episode or attack?
Generalized Anxiety Disorder - Answer: ✅✅worries most of the time about many different concerns, both reasonable and unfounded, several episodes of worry to occur on most days for at least 6 month period of time, worry is impossible to control and usually associated with somatic symptoms such as sleep, muscle pain, bowel function, or mood, or prob at work or relationships
Questions to ask: have you been worried about many things for over the past 6 months? Are these worries present most days? Did you find it difficult to control your worries? Do they interfere with your ability to concentrate on what you are doing?
Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) - Answer: ✅✅Often overestimate the danger in phobic situations and that older individuals often misattribute phobic fears to aging
-anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account
-6 month duration
Agorophobia - Answer: ✅✅Often overestimate the danger in phobic situations and that older individuals often misattribute phobic fears to aging
-anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account
-6 month duration
Specific Phobias - Answer: ✅✅- extreme fear and anxiety upon encountering insects, heights, cramped quarters, clowns , excessive and unreasonable, 6 months, only one situation or else agoraphobia if more than one
Social Anxiety Disorder/Social Phobias - Answer: ✅✅- marked fear of being the center of attention or behaving in a way that will result in embarrassment or humiliation
Subset: individuals who fear performing in front of audience
-excessive and unreasonable, last for 6 months or longer
Separation Anxiety Disorder - Answer: ✅✅avoidance behavior can occur at work or school, when a new parent returns to work and places an infant in the care of another, can be adults too
Other specified and unspecified obsessive compulsive and related disorder - Answer: ✅✅: body focused repetitive behavior disorder, obsessional jealousy, unspecified obsessive-compulsive and related disorder
-body focused repetitive behavior disorder is charactiverized by recurrent behaviors other than hair-pulling and skin-picking (nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors
-obsessional jealousy - non delusional preoccupation with a partners perceived infidelity
Medical conditions associated with anxiety - Answer: ✅✅hyperthyroidism, CHF, asthma, COPD, malignancy, pheochromocytoma, hyper adrenal, hypoglycemia, epilepsy, MI
Mood Disorders - Answer: ✅✅Major depressive disorder, cyclothymic disroder, bipolar disorder, seasonal pattern depression, postpartum depression, and premenstrual dysphoric disorder
Disruptive mood dysregulation - any person up to 18 who exhibits persistent irritability and frequent epsiodes of extreme behavioral dyscontrol
-persistent depressive disorder - includes chronic major depressive disorder an dysthymic disorder
-mixed symptoms allowing for possibility of manic features in individuals with a dx of unipolar depression
-with anxious distress specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders and increases the likelihood that the illness exists in a bipolar spectrum, but if the individual concerned has never met criteria for a manic or hypo manic episode, the dx of MDD is retained
Medical problems that can present with symptoms of depression: Addison's disease, AIDS, anemia, asthma, chronic fatigue syndrome, chronic infection, CHF, Cushings disease, diabetes, Hyperthyroidism, Hypothyroidism, Infectious hepatitis, malignancies, menopause, MS, postpartum hormonal changes, premenstrual syndrome, rheumatoid arthritis, systemic lupus, ulcerative colitis, uremia
Drugs that can cause depression: anti hypertensives (reserpine, propranolol, methyl dopa,guanethidine monosulfate, and clonidine hydrochloride), corticosteroids and hormones (cortisone acetate, estrogen, progesterone), antiparkinsonian drugs (levodopa and carbidopa, amantadine hydrochloride), anti anxiety drugs (diazepam, chlordiazepoxide), accutane, birth control pills
Major Depressive Disorder - Answer: ✅✅severe sleep disturbance, hypersomnia, weight gain, weight loss, avolition, restlessness, agitation, change in mood, cognition, behavior and motor function
-combo of psychotherapy and medication is most effective approach
-30% deny being depressed
-Hamilton rating scale for depression helpful
-assessment includes questions to identify whether the person is experiencing a general loss of pleasure in life or in activities he or she usually enjoys
-Symptoms: mood: depressed mood, anhedonia, loss of reactivity, loss of self-stem, tears, loss of hope, loss of interest, social withdrawal. Psychomotor retardation symptoms: loss of energy, cognitive symptoms, subjective inability to concentrate, pessimism, general rating of anxiety, decreased interest in activities, subjective inefficient thinking, thoughts of dying, free-floating anxiety, phobias. Behavioral symptoms: psychomotor agitation, irritability, guilty ideas of reference, depressed mood worse in morning, sleep disturbance, early waking, subjectively decresbed restlessness, suicidality, fatigue and exhaustion, loss of appetite or increase appetite (carb craving), hypersomnia
-Determine whether there is any sense of being sad or a general dysphoric mood and whether any neurovegetative symptoms are evident
-individual must have symptoms over a 2 week period that represent a change from previous functioning with at least one of the symptoms being a depressed mood or a loss of interest or pleasure
-five of the 9 criteria for major depression must be met during a 2-week period as well as either depressed mood or diminished interest during the 2 week period
depressed mood most of the day, nearly every day, as indicated by either subjective report (feels sad or empty) or observation made by others (appears tearful). Children and adolescents may display irritability
mar
Bereavement - Answer: ✅✅duration is 1-2 years, severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, more likely to occur in individuals with past personal and family history of major depressive episodes
-genetically influenced, assoc with similar personality characteristics, patters of comorbidity and risks of chronicity and/or recurrence as non bereavement related major depressive episode
-respond to the same psychosocial and medication as nonbereavement related depression
Mixed Features - Answer: ✅✅the coexistence within a major depressive episode of at least three manic symptoms is now acknowledged by the specifier "with mixed features"
Bipolar 2 - Answer: ✅✅determined when the clinical course includes one or more major depressive episodes and at least one hypo manic episode
-distress or impairment in social, occupational or other important areas of functioning
-the individual has not experienced a manic or mixed episode
Cyclothymic Disorder - Answer: ✅✅-chronic, fluctuating mood disturbance, including hypo manic and depressive symptoms that don't meet criteria for manic episode
-lack the severity, pervasiveness or duration
-symptoms must be present over 2 year period without a lapse of symptom longer than 2 months
-can stil function in social, occupational and other ares
-temperamental, moody, unpredictable, inconsistent, unreliable
Questions for suicide risk: have you been thinking that you would be better off dead or wishing that you were dead? Do you have thoughts of harming yourself? Have you been thinking about suicide? If you have been thinking about suicide, do you have a plan? If so, describe the plan. Have you recently attempted suicide? In the past, have you thought about or attempted suicide?
Seasonal Pattern - Answer: ✅✅features similar to those of bipolar or major depression, episodes begin in fall or winter and remit in the spring, mood is not related to situational stressors or cyclical patterns of work or life demands
Postpartum Depression - Answer: ✅✅immediate or 6 months after delivery, often mask their underlying depression, phenomenal called smiling depression, fluctuation in mood, mood lability, preoccupation with the infants well being, severity is key, thoughts can range from focused and realistic regarding the infants well being to obsessive or even delusional, highest risk is with psychotic features, Edinburgh postnatal depression scale
Distinguish between blues, depression and psychosis
Blues - rapid onset, transitory course, moody, irritable, anxious
Depression - onset generally within first postnatal month, symptoms and course of major depression; prominent anxiety, rumination (esp about baby's health), insomnia
Psychosis - most serious, rare, probably bipolar variant, symptoms of severe mood lability, irritability, anxiety, agitation, confusion, psychosis, sleep disruption, bizarre behavior, risk of infanticide
Premenstrual Dysphoric Disorder - Answer: ✅✅recurrent symptoms that occur during the lute all phase of the menstrual cycle and remit during menstruation
-diff dx include bipolar, thyroid dysfunction, prementsrual syndrome, exacerbation of unipolar disorder, anxiety, and cyclothymic disorder
-track symptoms for at least.2 months
-note recurring physical and emotional symptoms in late luteal phase, dissipating 1 or 2 days after menses
-encourage prospective rating of symptoms
-document precipitants
-document treatment response history
-rule out medical illness with symptoms that mimic premenstrual syndrome
-obtain family psychiatric history
-note use of stimulants, other mood-altering agents, water-retaining drugs
Substance Related Disorders - Answer: ✅✅mild substance use disorder requires at least two symptoms, owing to the effect of certain substances on mood, cognition, perception and behavior
-antisocial personality disorder is present in high percentage, others include mood disorder and anxiety
-physical dependence of marijuana isn't part of the clinical picture
-abuse for a cultural perspective is the self-admin of any drug in a culturally disapproved manner that causes adverse consequences
-diff dx - rule out delirium, dementia, and amnesic disorder
-change in cognition, including memory impairment and disturbed consciousness
-if no change of consciousness or memory impairment is present, then look for specific sx
-if substance is identified, consider whether a causal relationship exists bw the subtsance use and psychiatric sx
-are the symptoms a direct effect of the substance? Is the substance abuse a means of "self- medicating" for a primary psychiatric disorder? Are the psychiatric symptoms and substance abuse independent from one another?
-timing of the development of psychiatric symptoms and substance use will help determine whether the patient has a primary psychiatric condition or a true substance-abuse disorder
-can mimic many common psychiatric symptoms, depression, apathy, agitation, anxiety, panic attacks, thought disturbances, paranoia, and psychosis
Eating Disorders - Answer: ✅✅-dominant feature of anorexia is to lose weight
-common patterns include restricting food intake and exercising excessively
