Soap - case history taking en ostéopathie pour les mémoires

Pages: 5 (1071 mots) Publié le: 4 novembre 2010
Outpatient Osteopathic SOAP Note—Follow-up Form
wak SOAP Follow-up version 2:11403b

Patient’s Name ______________________________ Age _______ Resp. ____
* Vital Signs (3 of 7) Reg.

Date ______

Sex:

Male

Female
Temp. _________

Office of: For office use only:

Wt. ____________

Ht. _____________

Pt. position for recording BP

Pulse ____

Irreg.

Standing_______Not done

Sitting________

Lying_________

S Patient’s Pain Analog Scale:
NO PAIN

WORST POSSIBLE PAIN

CC: HPI: (Location, Quality, Severity, Duration, Timing, Context, Modifying factors, Associated Signs and Sx) PFSH: ROS: (Constitutional, Eyes, Ears/Nose/Mouth/Throat, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine,Hematologic/Lymphatic, Allergic/Immunologic)

Meds:

Level: HPI
II III IV V 1-3HPI 1-3 HPI 4+ HPI 4+ HPI

Level ROS
II III IV V None 1 ROS 2-9 ROS 10 + ROS

Level of PFSH
II III IV V None None 1 PFSH 2 + PFSH

Overall History = Average of HPI, ROS or PFSH:

II ( 1-3 HPI)

III ( 1-3 HPI, 1 ROS)

IV (4+ HPI, 2-9 ROS, 1 PFSH)

V (4+ HPI, 10+ ROS, 2+ PFSH)

O

Level of GMS
II III IV V1-5 elements 6 + elements 2 + from each of 6 areas OR 12 + elements in 2 + areas 2 + elements from each of 9 areas

Signature of transcriber: ________________________________

Signature of examiner:

________________________________________________

Funded by a grant from the Bureau of Research. © 2002 American Academy of Osteopathy. Designed to coordinate with the Initial OutpatientOsteopathic SOAP Note Form. Recommended by American Association of Colleges of Osteopathic Medicine.

Page 1 of 2

Outpatient Osteopathic SOAP Note—Follow-up Form
Patient’s Name _________________________________ Date __________________

wak SOAP Follow-up version 2:11403b Office of: For Office use only:

O (continued)
Exam Method Used
All T A R T *1

Severity Scale:
All not done

0 = NoSD or background (BG) levels 2 = Obvious TART (esp. R and T), + /- symptoms 1 = More than BG level, minor TART 3 = Key lesions, symptomatic, R and T stands out Somatic Dysfunction / Other OMT Treatment Method Severity 0 1 2 3
MS/SNS/PNS/LYM/CV/RESP/GI/FAS/ etc.

Response
R I U W

*2

*3 *4 *5 *6

Region Head and Face Neck Thoracic T1-4 T5-9 T10-12 Ribs Lumbar Sacrum / Pelvis Pelvis /Innom. Abd ./ Other Upper R Extremity L Lower R Extremity L

Y

N

(Circle Method Used)
ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND / INR / ART / BLT / IND /INR / ART / BLT / IND / INR / CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VISCR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS CR / CS / DIR / FPR / HVLA LAS / ME / MFR / ST / VIS

Physician’s evaluation ofpatient prior to treatment:

First visit

Resolved

Improved

Unchanged

Worse

A
Dx No. ______ ______ ______ ______ ______ Written Diagnosis __________________ __________________ __________________ __________________ __________________ ICD Code _______ _______ _______ _______ _______ Dx No. ______ ______ ______ ______ ______ Written Diagnosis SD Head and Face SD Neck SD Thoracic SD...
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