Class Notes

Question 1

SOAP

Answer 1

subjective
objective
assessment
plan

Question 2

subjective

Answer 2

based on the patients feelings

CC, HPI, and ROS

Question 3

objective

Answer 3

factual information from provider (PE)

Question 4

history of present illness (HPI)

Answer 4

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

Question 5

review of systems (ROS)

Answer 5

head to toe check list of patients symptoms

Question 6

intermittent

Answer 6

comes and goes

Question 7

waxing and waning

Answer 7

always present but changing in intensity

Question 8

modifying factor

Answer 8

something that makes a symptom better or worse

Question 9

exacerbate

Answer 9

to make worse

Question 10

attestation

Answer 10

the scribe and providers sign off that the chart was prepared by a scribe then approved by provider

Question 11

elements of the HPI

Answer 11

onset
timing
location
quality
severity
modifying factors
associated Sx
context

**CC is not count as an element of the HPI

Question 12

onset

Answer 12

when did the complaint begin

Question 13

timing

Answer 13

has it been constant, intermittent, or waxing and waning

fequency?

Question 14

location

Answer 14

where is the discomfort

Question 15

quality

Answer 15

does it feel sharp, dull, aching, cramping…?

Question 16

severity

Answer 16

How bad is it? Mild, moderate, severe or 0-10

Question 17

modifying factors

Answer 17

What makes it better or worse?

Have you tried anything?

Question 18

associated Sx

Answer 18

Do any other symptoms accompany the complaint?

Are there any pertinent negatives?

Question 19

context

Answer 19

is there anything else that’s important?

Question 20

cachectic:

Answer 20

emaciated, malnourished

Question 21

chief complaint

Answer 21

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

Question 22

what four phases should not be used because they can make something non reimbursable

Answer 22

• follow up
• check up
• Lab results
• medication refill

use words like management, or management evaluation, or evaluation medication management, or discuss treatment options for

Question 23

assessment

Answer 23

• 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

Question 24

results summary

Answer 24

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

Question 25

what does the plan include

Answer 25

• recommended treatment(s) for each diagnosis (lifestyle change, OTC medications)
• prescriptions ordered today
• studies/ tests. labs/ imaging ordered today
• follow up with other health care professionals
• follow up here: when should the patient return

every plan needs to end with when the next visit/ follow up is

Question 26

Plan

Answer 26

the currently laid out course of action to address the patient’s condition

• a list outlining how the doctor will treat and/ or monitor the patient
• this is the last thing on the chart
• this will be in bullets or numbers
• this should be recorded in the room with the patient because the doctor will say these out loud so remember to listen up

Question 27

MACRA

Answer 27

medicare Access and CHIP reauthorization Act

Question 28

CMS:

Answer 28

Centers for Medicare and medicaid services

Question 29

MIPS:

Answer 29

Merit- based incentive payment system

Question 30

CPOE:

Answer 30

computerized physician order entry

Question 31

EHR

Answer 31

Electronic health record

Question 32

EMR

Answer 32

electronic medical record

Question 33

diagnosis

Answer 33

what the physician has determined to be the most likely cause of the patients symptoms

Question 34

assessment

Answer 34

a list of the patients current diagnoses

Question 35

prognosis

Answer 35

a forecast of the likely course of a disease or ailment

Question 36

follow up

Answer 36

on going contact with healthcare providers in order to address a health concern