course 3 soap

Question 1

SOAP is what

Answer 1

documentation method for healthcare providers. Subjective, Objective, Assessment, Plan

Question 2

Subjective components in SOAP consist of what?

Answer 2

Chief complaint, HPI, history of present illness, ROS, review of systems.

Question 3

HPI elements? What does the OTLQSMAC mnemonic stand for and what does it mean

Answer 3

Only Tall Lads Quit Soccer Matches And Cry. (onset, timing, location, quality, severity, modifying factors, associated sx, context)

Question 4

Examples of NON REIMBURSABLE chief complaint phrases

Answer 4

Check-up, Follow-up, Lab results, Medication refill.

Question 5

How to fix “Check-up” in chief complaint section

Answer 5

________ management visit

Question 6

How to fix “Follow-up” in chief complaint section

Answer 6

________ management evaluation

Question 7

How to fix “Lab-results” in chief complaint section

Answer 7

discuss treatment options for _________

Question 8

How to fix “medication refill” in chief complaint section

Answer 8

evaluation of medication management for _______

Question 9

is HPI S or O? What is it

Answer 9

it is in the subjective section. A story of symptoms and events leading to the clinic visit, summarizes in total the reason for the visit. BASIS FOR ENTIRE WORKUP

Question 10

How does ROS differ from HPI

Answer 10

ROS also includes symptoms not relevant to chief complaint and HPI, completely contextless

Question 11

Most important tips?

Answer 11

HPI always begins with age and sex of patient. Complete sentences, good english. Answers to EVERY QUESTION must be documented. Word HPI as a doctor would speak.

Question 12

What are the different ways HPI’s are structured

Answer 12

Single complaint, multiple complaint, chronologic formula

Question 13

What is the most commonly used and simplest HPI structure? What does it look like

Answer 13

Single complaint. Used for 1-2 previously unevaluated complaints

Question 14

What is the HPI formula used for primary care, and why. how is it structured

Answer 14

Multiple complaint formula. PCPs dicusses every complaint in detail with patient. New paragraph for each condition

Question 15

What is the most complex HPI structure, why is it used

Answer 15

chronologic, used for complex stories for patients with multiple comorbidities, lots of evaluation or workup, or established patients following up on chronic illness.

Question 16

What is the structure of a chronologic formula HPI

Answer 16

begins with chronologic recap, which includes age and sex, relevant PMHx, previous evaluations and treatments. Then goes to regular HPI for current complaint (he presents/returns today for ____)