A.
SOAP Notes (Subjective, Objective, Assessment, Plan)
- Watch and listen to video of patient-doctor encounter (2x will be played)
- Template provided during QE
- Take down important details
Subjective - History section, patient’s narration, medical history, social history, family
history, surgical history, current medications and allergies, HPI (History of Present Illness -
patient’s age, sex, and reason for the visit):
Elaborate chief complaint (CC); Guide on how to document effectively “OLDCARTS”
ROS (Review of Systems) - mainly based on the pt’s symptoms:
Objective – if chinicheck na ni Doc si patient using medical devices (e.g. stethoscope).
Mainly based on the findings of the doctor during the physical exam.
Assessment – Diagnosis of the doctor. List of differential diagnosis. Possible multiple
diagnosis. List of problems identified (must be supported by the subjective and objective
parts of the notes).
Plan – Laboratory requests, referrals, medications, procedures, therapy that might be
needed by the patient, patient education and counseling.
Tips:
- Use shortcut words in taking down notes, then modify it in editing part
- HPI and ROS should always match
Bali sis may ibibigay sila na format
Subjective
-type mo dito yung mapapanuod mo sa video na under subjective
Head : bsbsjanahajbab
Eyes : bshajanshsjzbba
Ears: sbhajabsbs
Ganan ang sample-
Bali may mga nakasulat jan sa head, ears, eyes , nose
TECHNIQUE SA SUBJECTIVE
- kung ano lang sinabi ni patient na nasakit or problem nya, yun lang ababguhin mo.
Example- sabi ni pt naka exp sya ng blurry vision
Eyes: Patient is positive for blurry vision
Ear: if wala sinabi si pt dito, wag mo buburahin at babaguhin
Technique sa OBJECTIVE
Kung ano lang ang chineck ng doctor yun lang ang babaguhin mo.
Pag di chineck ni doctor yung eyes. Pwede mo burahin.
Pero yung HEAD at NEURO (pinaka una at pinaka dulo) kahit hindi chineck wag mo
babaguhin at buburahin
Tapos sa assessmet
If maalam ka humanap ng ICD10code lagyan mo.
Pero ako nun wala ako nilagay na ICD10 ahahhahaha
Kung ano lang sinabi ni doctor yun nilagay ko na assessment
Plan
- mahalaga makumpleto mo to sis
- summarized pero with important details
Patient is a 35-year-old female who presents with a 2-week history of worsening shortening of
breath and a persistent cough. [ONSET] The patient reports that the shortness of breath begins
gradually and has progressively gotten worse, to the point where she is now unable to walk more
than a few steps without feeling out of breath. The cough is described as non-productive and has
been present for the same duration as the shortness of breath.
The patient denies any chest pain, fever, or chills. She reports feeling fatigues and losing her
appetite in the past few days. The patient has a history of asthma, which has been well-controlled
with regular use of inhaled medications. She denies any recent changes in her asthma
management or any exposure to any new trigger. The patient works as a teacher and reports that
she has not been able to perform her duties as efficiently due to her symptoms.
B. Referral Letter
T (/) - Tick for important details
C (X) - Cross not important
O – Optional
*Check the dates – 1st and 2nd visits – Date of Notes
*Information that is relevant to the HCP who you will be writing to
AED – Attends Emergency Dept
P/E – Physical Examination
RUQ – Right Upper Quadrant
CXR – Chest X-ray
V/S – Vital signs
XR - Xray
Sample template
Date: June 12, 2023
To:
[NAME]
[ADDRESS]
Re: Ashley Kim DOB:10/02/1992
[INTRO] I am writing to refer this patient, a 25-year-old Korean women, who is recovering from injury
from injuries following a domestic abuse incident.
[SOCIAL HISTORY] Ashley was living with her boyfriend, Brad park, and their 5-year-old son, Alex Park.
She was working as a part-time waitress and Brad had been unemployed for 18 months and has a history
of binge drinking. Alex was attending childcare when Ashley was working.
[PAST MEDICAL HISTORY] Since August 2017, Ashley has been presented to the emergency department
on 3 occasions with a range of injuries including bruising, fractures, and burns. Appropriate medical
treatment and case has been provided each time. However, Ashely has refused pyschological support
and also denied the possibility of domestic abuse. [trend of events in summary]
[RECENT HISTORY – Details of most recent visit] On 20/02/2018, a serious incident of domestic abuse
occurred, due to which Ashley received significant burns to her lower limbs and her life was threatened.
A neighbour called police and Brad Park was arrested. She was transferred by ambulance to the
Emergency Department and is currently being treated for her burn injuries.
[DISCHARGE PLAN] Her son is under the case of our hospital’s Child Welfare Centre. Please note, they
have also been referred to a clinical psychologist for possible post-traumatic stress disorder counselling
and emotional support.
I would appreciate it if you could provide shelter for both Ashley and her son after discharge.
Your sincerely,
Burn Ward
Brisbane Spirit Hospital
Sample template
Ms. Ma. Celeste Gomez
MESU Coordination/RHU Nurse
Poblacion Suralla, Bohol City
June 12, 2023
Dr. Ms. Gomez,
I am writing to refer this patient, a 36-year-old women, married, and who is recovering from COVID-19,
for your management and transportation. [reason for referral]. She is 36 yrs. old and married. She has a
history of Pneumonia and was hospitalized in year 2022. It has also been noted that she is a smoke since
the aged of 28 with approximately of 8 sticks/day and occasionally drinks 3-5 bottles of beer per week.
She is also allergic to dust and pollen. [social history, medical history]
She complains of having productive and worsening cough associated with thick whitish phlegm and chest
congestion for 7 days, body aches and chills for 8 days, and loss of appetite, dry throat, and positive
tonsillar swelling or exudate. She also complains of having headache for a week, and appears pale and
exhausted.
Negative for nausea, vomiting or diarrhea. The vital signs are temperature 38.4 C (febrile); pulse 87;
respirations 30 labored; oxygen saturation of 93% and blood pressure of 140/90. Minimal dizziness and
no palpitation. Maxillary sinuses are tender to touch and non-bulging. Upon auscultation of the lungs, it
was noted that there are positive coarse and congested crackles in the right base and middle section. It
has also been noted that the neck, groin, and axilla shows mild lymphadenopathy, which could mean
that the patient came into contact with COVID-19 positive.
Rapid antigen test and nasopharyngeal swab test confirms that the patient is indeed positive for COVID-
19. She was advised to isolate for the next 21 days with rest and increase fluid intake. She was also
advised to take vitamins and Zithromax Z-Pak 500mg once a day for 21 days by Dr. Aaron Fernandez. The
patient’s vital signs and progress of infection should be monitored and report to Dr. Christian Vasques, if
signs and symptoms worsen.
Lastly, after the 21 days quarantine she must be arranged to visit a GP for medical evaluation. The
patient was managed and released in stable condition.
We have referred her to you as we believe she would benefit from your care. Thank you.
Yours sincerely,
Alyssa Sarah P. Piramide, RPh
C. Computer Navigation Skill Test
1. https://www.proprofs.com/quiz-school/story.php?title=basic-
computer-skills-assessment / Score Report: Basic Computer Skills
Assessment Quiz at Free Online Quiz School (proprofs.com)
2. Computer Navigation Skills Test ! - Quiz, Trivia & Questions (proprofs.com) / Score
Report: Computer Navigation Skills Test ! at Free Online Quiz School (proprofs.com)
F7 – check the spelling
F2 or Right click and select “Rename” – rename
F5 – refresh web page in most web browser
3. Computer Quiz Online Test - Question 1 (proprofs.com) / Score Report: Computer
Quiz Online Test at Free Online Quiz School (proprofs.com)
D. Medical Terminologies
Aphagia – unability to swallow
Aphasia – unability to speak
Anakusis / Anacusis – unability to hear
Crapulent – excessive drinking
Phlebitis – vein inflammation
Cicatrix – scar
Pyrosis – Heartburn
Morbilli – measles
Thyroid gland – responsible for metabolism
Monaural – one ear
Scurvy – Vit C deificiency
Rickets – Vit D deficiency
Beri-beri – Vit B1 (thiamine) deficiency
Pellagra – Vit B3 (niacin) deficiency
ADEK – fat soluble vitamins
Bile – produced by the liver
Larynx – medical term for voice box
30 Medical trivia Quiz Questions and Answers – OnlineExamMaker Blog
Health 103: Medical Terminology - Practice Test Questions & Final Exam | Study.com
Diseases, Disorders, and More: A Medical Quiz | Britannica
Test Your Medical Knowledge - Question 1 (proprofs.com)
Quiz: Can you pass a basic medical terms test? - Washington Times
