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OMSII Tips for Success

Objectives
Review useful mnemonics Review SOAP note writing Demonstrate Ideal SOAP notes Discuss SP checklists Display a sample Grading Rubric

Useful Mnemonics

Useful Mnemonic for History Taking: COPMAPS


C = Complaint O = Onset (when, how, duration) P = Progression (has it changed over time) M = Mitigating factors (better, worse) A = Associated symptoms P = Previous occurrence (diagnosis, treatment) = Pertinent other (social history, allergies,
medications, past medical history, surgical history, family history)

S = Summarize

Useful Mnemonic for Joint Evaluation: HIPROT


H History (again, think COPMAPS) I Inspection P Palpation R Range of Motion O T Other tests: Muscle strength testing
Deep Tendon Reflexes Sensory testing Special tests (see attached documents
specific for upper and lower extremity

Useful Mnemonic for Depression Evaluation: SIGECAPS


Sleep: Insomnia or Hypersomnia Interest: Loss of interest or pleasure in activities Guilt: Feelings of excessive guilt or hopelessness Energy: Fatigue or loss of energy Concentration: Diminished ability to concentrate Appetite: Decreased or increased appetite Psychomotor: Retardation or agitation Suicidality: Thoughts of suicide, suicide plans or attempt, or preoccupation with death

Useful Mnemonic for Mental Status Evaluation: FOGS


F = Family story O = Orientation G = General Information S = Spelling Supplementary: count backwards from 100 by 3's, repeat 7 digit no., recall 3 objects after several minutes. Not a mnemonic, but MMSE in next slide for review.

Useful Mnemonic for Alcohol Use Screening: CAGE


Have you ever tried to Cut down your use of alcohol (drugs)? Have people ever Annoyed you by criticizing your drinking (use of drugs)? Have you ever felt Guilty about your drinking (use of drugs)? Have you ever used a drink (drug) as an Eye opener in the morning to get going?

Useful Mnemonics
COPMAPS can be used in all history taking encounters. Other mnemonics should be used if relevant to the specific case. You will not be counted off for not using a mnemonic, but you will be expected to have obtained all of the necessary information- which is sometimes easier to gather if you use a mnemonic.

SOAP Notes

The Basics
S = Subjective Data O = Objective Data A = Assessment P = Plan

Subjective = History
Identifying data Chief complaint in chronological order start with the most current episode History of the present illness/chief complaint COPMAPS include pertinent positive AND negative reports

Subjective = History
Pertinent other is an area often overlooked Should consist of PMH, Surg Hx, Meds,

Allergies (specifically medication; food and environmental if may be pertinent), Fam Hx, Soc Hx as relevant to the chief complaint or as necessary documentation for a new patient Caution: If you do not ask, you may not know if an item is relevant or not!

Subjective = History
May include information from others & reported test results Use only approved abbreviations Needs to be readable, i.e., make sense to the reader Need to mark errors with single line, initial, and date

Objective = Exam Findings


Physical exam Vital signs Detail the systems involved in the chief complaint
Document from top to bottom
HEENT, CV, Lungs, Abd, Ext, etc

Include pertinent positive AND negative findings


Use approved abbreviations Never use only WNL or normal

Laboratory and Radiographic data

Assessment = The Problem List


Your Diagnoses
List of terms Most likely diagnosis listed first Must be codeable Must be addressed in your upcoming plan

Plan
Includes: Treatments (preventive, therapeutic, medication additions/ cancellations/ dose changes) Diagnostic evaluations (lab, XRs, consults) Patient education Follow-up instructions (must have!) Needs to correlate with your assessment

Ideal SOAP Notes

Ideal SOAP Notes


MUST BE LEGIBLE! Need to have information in the right position (S-O-A-P) Need to be thorough
All of the information obtained during your history and physical needs to be documented. Remember, if it is not documented, it did not happen.

SP Checklists

SP Checklists
Standardized patients score students on: History taking skills Physical exam skills OMM skills Patient centered care
Respectful of patient; assisted patient when needed

Communication
Verbal and nonverbal considered

Grading Rubric

Grading Rubric
SOAP notes are graded by faculty
Most often by the faculty member who wrote the case.

There may be some variation of points within a section due to differences in important points of cases.

OMSII Tips for Success: Summary


Be thorough
With taking a history, performing a physical exam, and writing your SOAP note

Remember your patients


Treat them as you would want to be treated.