EssayproSolutions

C: What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. HPI: Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] PMH: This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. ALLERGIES State the offending medication/food and the reactions. MEDICATIONS Names, dosages, and routes of administration along with indication of use. SH Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. FH Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. HEALTH PROMOTION & MAINTENANCE Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. ROS (put N/A in sections not completed day of exam) Constitutional Head Eyes Ears, Nose, Mouth, Throat Neck Cardiovascular/Peripheral Vascular Respiratory Breast Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) Endocrine Hematologic/Lymphatic Allergic/Immunologic Other