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.