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  1. Subjective
    • CC, HPI, PMH, SH, FH, ROS, Allergies, Medications
    • Descriptive, cannot be measured directly
  2. Objective
    • Physical Exam, Vital signs, Laboratory tests, CrCl, Serum drug conc., Diagnostic test results, Medications
    • can be measured, often numerical
  3. Assessment
    • Disease Assessment + Supporting Evidence
    • -Uncontrolled asthma secondary to improper medications use as evidenced by RR of 24 and history of smoking
    • GOALS
    • -Clear, achievable, and measureable, guidelines, communicated
  4. Plan
    • Pharmacologic
    • -Drug, Dose, Route, Schedule, Duration
    • Non-pharmacologic
    • Education/Counseling
    • Monitoring/Foloow up
    • Rationale
  5. Tips for SOAPs
    • Includes your name and date
    • Shor and to the point
    • do NOT include unnessessary info
    • BP, RR, HR, CrCl
  6. Importnace of documentation of SOAPs
    • Valuable communication tool
    • Permanent record
    • Legal record
    • Back-up for billing purposes
  7. PMS(Pre-menstrual syndrome)
    • 4-10 days prior to menses
    • Primary Dysmenorrhea
    • Secondary dysmenorrhea
    • Premenstrual dysphoric disorder (PMDD)
  8. PMS treatment
    • PMDD or secondary dysmenorrhea-Referral
    • Symptomatic therapy: Analgesics, Pyridoxine (Vit B6), Pyrilamine or pamabrom, Caffeine
  9. UTI
    • Dysuria: painful, burning sensation while urinating
    • Hematuria: blood in the urine
    • Pyelonephritis: kidney inflammation due to bacterial infection
    • Treatment: antibiotic, phenazopyridine(Azo) for symptomatic relief
  10. Vulvovaginitis (Types)
    • Candidal infection: think, curd-like discharge wiht yeast-like odor-OTC
    • Bacterial infection: thin or creamy discharge with fishy odor
    • Trichomonal infection: Copious, fothy discharge
    • Atrophic vaginitis: Blood-tinged discharge
  11. Vulvovaginitis (Assessment)
    • Dyspareunia: painful sexual intercourse
    • Vaginal dryness: Atrophic vaginitis
    • Medication can predispose the patients
    • yeast infection
    • Postmenopausal women can have atrophic vaginitis
  12. Menopausal symptoms
    • 12 months between 48-55 yo
    • Symptoms: hot flashes, flushing, sweating, disturbances in sleep, vaginal dryness or atrophy
    • Thromboembolic events or breast cancer, niacin
    • HRT, Osteoporosis
  13. Pregnancy
    • Leukorrhea: increased vaginal secretions
    • Amenorrhea: absence of menses
    • Heartburn, Edema, and etc.
    • Gravida: total number
    • Para: outcomes
    • Refer when: vaginal bleeding, cramping, persistent headache, visual changes, 5% weight loss
  14. Hormonal contraception
    • If side effects last longer than 3 months: referral
    • Side effects: Breast tenderness, nausea and vomiting, abnormal menstrual bleeding, breakthrough bleeding, vginal dryness, vaginitis, weight gain, acne
    • Refer immediately: severe abdominal pain(pancreatis), chest pain, severe headaches, vision issues, DVT
  15. General info for chart
    • No scratch,erase
    • Contents: Admission data, History and physical, Physician Orders, Lab Results, Progress Notes, Nursing Notes, Procedures/Consults, MAR
  16. Morbidity
    Disease or disability
  17. Types of prevention
    • Primary: Immunization, education
    • Secondary: early detection, screening
    • Tertiary: Reduce impact of disease (med use)
  18. Evidence-based recommendations
    • A: strongly recommends
    • B: recommends
    • C: no recommendation for or against
    • D: recommends against
    • I: insufficient evidence to recommend for or against
  19. 5 A behavioral counseling framework for tobacco
    • Ask about tobacco use
    • Advise to quit through clear, personalized messages
    • Assess willingness to quit
    • Assist to quit
    • Arrange follow-up and support
  20. Alcohol counseling
    • CAGE: Cut down, Annoyed, Guilty, Eye-opener, more than 2 = alcohol dependent
Card Set
Patient Care Accessment Module
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