• Question

    Obtaining a patient’s medical history is generally considered the most important step in developing a differential diagnosis. It has been stated that history-taking contributes around 80% towards the diagnosis with many texts relating to an article by Hampton et al. (1975). According to Talley and O’Connor (2013) an comprehensive history will aid in identifying the most appropriate investigations required and in most case lead to the diagnosis. The physical examination and investigations which follow history taking are merely to confirm or refute the differentials.

  • Practitioners will encounter a large proportion of patients presenting with pain as their main presenting complaint regardless of the speciality. To ensure that a proper history is obtained from the patient the mnemonic "SOCRATES" can be used as a prompt.

    It can be used for various types of pain; cardiac, abdominal, muscular, headaches, and much more. The SOCRATES mnemonic can be broken down as detailed below:

    Site; where exactly is the pain?

    Onset; what were they doing when the pain started?

    Character; what does the pain feel like?

    Radiating; does the pain go anywhere else?

    Associated symptoms; e.g. nausea/vomiting?

    Time/duration; how long have they had the pain?

    Exacerbating/relieving factors; does anything make the pain better or worse?

    Severity; what is their pain score?

  • It can be a daunting prospect; the thought of writing in medical notes as a nurse practitioner and them being scrutinised by senior colleagues. To aid in the process of documentation, a SOAP approach can be used.  SOAP is a method of documentation originally developed for physicians in the 1960's by Dr Lawrence Weed at the University of Vermont. However, it is now used as an important documentation writing tool for all healthcare providers.
    Using SOAP documentation provides a methodical approach to writing clinical notes. They enable the practitioner to produce written evidence of patient contact and outline their clinical decision-making process.
    The four elements of SOAP are:
    Each element of the SOAP should be explored in the specific order of the acronym.
    Subjective: this relates to the information provided to the practitioner by the patient and should include:
    the patients presenting complaint (PC) in their own words
    the patient's history of presenting complaint (HPC)
    can use SOCRATESor OLD CARTS
    include tests, referrals, treatments and outcomes
    past medical and surgical history
    can use the mnemonic JAM THREADS
    previous operations or procedures
    previous anaesthetics and treatments
    vaccination history
    family medical history
    social history
    diet and exercise
    occupational history
    travel history
    sexual history
    review body systems
     Objective; this relates to the information from observations, examination and test results such as:
    vital signs and measurements including height and weight
    examination findings
    laboratory test results
    radiology results
    medication lists from pharmacy, GP or medical records
    Assessment; this includes advice for lifestyle changes, your diagnosis and differential diagnosis.
    Plan; this is where you include your plan of treatment including:
    further tests

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