Class Notes Flashcards
SOAP
subjective
objective
assessment
plan
subjective
based on the patients feelings
CC, HPI, and ROS
objective
factual information from provider (PE)
history of present illness (HPI)
the story of the patient’s chief complaint
this is going to summarize the reason for the visit and will be at the beginning of the chart
the entire clinic visit is based on the HPI and anything that is labeled as a chief complaint in the HPI needs to be followed throughout the entire chart and have a diagnosis at the end
review of systems (ROS)
head to toe check list of patients symptoms
intermittent
comes and goes
waxing and waning
always present but changing in intensity
modifying factor
something that makes a symptom better or worse
exacerbate
to make worse
attestation
the scribe and providers sign off that the chart was prepared by a scribe then approved by provider
elements of the HPI
onset timing location quality severity modifying factors associated Sx context
**CC is not count as an element of the HPI
onset
when did the complaint begin
timing
has it been constant, intermittent, or waxing and waning
fequency?
location
where is the discomfort
quality
does it feel sharp, dull, aching, cramping…?
severity
How bad is it? Mild, moderate, severe or 0-10
modifying factors
What makes it better or worse?
Have you tried anything?
associated Sx
Do any other symptoms accompany the complaint?
Are there any pertinent negatives?
context
is there anything else that’s important?
cachectic:
emaciated, malnourished
chief complaint
the main reason for the visit
this needs to ALWAYS be included because it is needed for all levels of billing
important for legal reasons
what four phases should not be used because they can make something non reimbursable
- follow up
- check up
- Lab results
- medication refill
use words like management, or management evaluation, or evaluation medication management, or discuss treatment options for
assessment
- these will vary based on specialty
- this will always include a diagnoses
can also include:
- summary of HOP
- summary of physical exam
- summary of lab/imaging
- prognosis
results summary
all new results are included in the objective part of the chart but ONLY the new and relevant to the diagnosis are summarized in the assessment
