omsii tips for success 2012
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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.
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