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IPDM I SOAP Abbreviations

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alchemist04's version from 2016-04-28 04:17

Section

Question Answer
CCChief Complaint. One or more symptoms or concerns causing the pt to seek care
HPIHistory of pt's illness. First statement usually identify pt's data such as age, gender and race. It amplifies Chief complains.
PMHPast Medical History. Include different types and dates of previous diagnosis
PSHPast Surgical History
FHFamily history
SHSocial History like alcohol use, drugs, tobacco. Family income, marriages, education, habits, job history, spiritual believes, ability to care for oneself etc
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Allergies: Allergies to medication
Question Answer
Current medicationsincluding OTC, vitamins, herbal or nutritional supplement. Describe patient's compliance
Past Medication HistoryOptional, depending on specialty
PTAMeds prior to admission. If admitted, Patient meds will change to inpatient med.
ROSReview of System. This is when you question patient pertaining to symptoms. Do from "Head to Toe"
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Question Answer
SSubjective. Data from patient or third party. For most part, PMH falls under her except it has been documented before. In that wise, it moves to Objective.
OObjective. This include all medical records like X-ray, previous diagnosis, lab report
AAssessment. This combine both subjective and objective with critical thinking, analysis and interpretation of all presented data.
PPlan. Outlines your plan of action. Include pharmacotherapy changes, monitor parameters and the efficacy of treatment
memorize

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