Course 3: The S.O.A.P Note - Subjective

Question 1

SOAP

Answer 1

subjective, objective, assessment, plan

Question 2

subjective

Answer 2

based on the patient’s feelings (HPI, ROS)

Question 3

objective

Answer 3

factual information from provider (PE)

Question 4

history of present illness (HPI)

Answer 4

• the story and context of the patient’s chief complaint
• story of symptoms and EVENTS that lead to clinic visit
• information DIRECTLY related to CC (all other info goes elsewhere on the chart)

Question 5

review of systems (ROS)

Answer 5

head-to-toe checklist of patient’s symptoms from all body systems

Question 6

intermittent

Answer 6

comes and goes

Question 7

waxing and waning

Answer 7

always present but changing in intensity

Question 8

modifying factors

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

Question 11

SOAP note

Answer 11

• method of organizing clinical information in a pt’s chart

- closely follows the workflow of the clinic

Question 12

S - subjective

Answer 12

-information directly from the patient giving the history:
in most cases, pt
possibly a parent for peds
possible son/daughter for elderly

• includes
  chief complaint (CC)
  HPI
  ROS

Question 13

O - objective

Answer 13

• factual information from the provider or clinic staff

- includes
  vital signs 
  PE
  orders
  results

Question 14

A - assessment

Answer 14

• the patient’s diagnoses

- a short description of progress since last visit

Question 15

P - plan

Answer 15

follow-up and treatment plan for each diagnosis

Question 16

chief complaint (CC)

Answer 16

• main reason for visit
• need to always include
• every level of billing requires a CC to be reimbursed for service provided

Question 17

non-reimbursable CC: check-up

Answer 17

ex. reimbursable = 3 month diabetes management visit

Question 18

non-reimbursable CC: follow-up

Answer 18

ex. reimbursable = HTN management evaluation

Question 19

non-reimbursable CC: lab results

Answer 19

ex. reimbursable = discuss treatment options for elevated TSH

Question 20

non-reimbursable CC: medication refill

Answer 20

ex. reimbursable = evaluation of medication management for HTN

Question 21

How do you “check” your SOAP chart for completeness?

Answer 21

find subjective complaints in the HPI and follow them through the rest of the chart (HPI, ROS, PE and/or results, assessment and plan)

Question 22

HPI - content

Answer 22

Every question the doctor asks is important!

• your goal is to capture the answer to every question the doctor asks
• you don’t have to write everything the pt says, but ALWAYS write the answers to the doctor’s specific questions
• each question is asked to help lower or raise his suspicion for a particular disease; this helps him to decide which tests to order
• **if your chart is missing the answer to a question, there is no record the doctor ever asked it

Question 23

A complete HPI contains the following elements: (hint: 8)

Answer 23

onset, timing, location, quality, severity, modifying factors, associated Sx, context

**the CC is not an element; the elements describe the CC!

Question 24

HPI element: onset

Answer 24

when did the complaint begin?

Question 25

HPI element: timing

Answer 25

has it been constant, intermittent, or waxing and waning?

Question 26

HPI element: location

Answer 26

where is the discomfort?

Question 27

HPI element: quality

Answer 27

does it feel sharp, dull, aching, cramping, etc.?

Question 28

HPI element: severity

Answer 28

how bad is it? mild, moderate, severe, or 0-10?

Question 29

HPI element: modifying factors

Answer 29

what makes it better? what makes it worse?

Question 30

HPI element: associated Sx

Answer 30

do any other symptoms accompany the complaint?

Question 31

HPI element: context

Answer 31

is there anything else that’s important?