Course 3: The S.O.A.P Note - Subjective Flashcards
1. What is a SOAP note and how is it structured? 2. What is included in the subjective portion of the SOAP note? 3. What is the chief complaint (CC) and how do we avoid non-billable chief complaints? 4. What is the history of present illness (HPI) and what information does it contain? 5. How is HPI structured? 6. How is the HPI phrased? 7. What is the review of systems (ROS) and what information does it contain? 8. How is the ROS structured?
SOAP
subjective, objective, assessment, plan
subjective
based on the patient’s feelings (HPI, ROS)
objective
factual information from provider (PE)
history of present illness (HPI)
- 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)
review of systems (ROS)
head-to-toe checklist of patient’s symptoms from all body systems
intermittent
comes and goes
waxing and waning
always present but changing in intensity
modifying factors
something that makes a symptom better or worse
exacerbate
to make worse
attestation
the scribe and provider sign off that the chart was prepared by a scribe then approved by a provider
SOAP note
- method of organizing clinical information in a pt’s chart
- closely follows the workflow of the clinic
S - subjective
-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
O - objective
- factual information from the provider or clinic staff
- includes vital signs PE orders results
A - assessment
- the patient’s diagnoses
- a short description of progress since last visit
P - plan
follow-up and treatment plan for each diagnosis
chief complaint (CC)
- main reason for visit
- need to always include
- every level of billing requires a CC to be reimbursed for service provided
non-reimbursable CC: check-up
ex. reimbursable = 3 month diabetes management visit
non-reimbursable CC: follow-up
ex. reimbursable = HTN management evaluation
non-reimbursable CC: lab results
ex. reimbursable = discuss treatment options for elevated TSH
non-reimbursable CC: medication refill
ex. reimbursable = evaluation of medication management for HTN
How do you “check” your SOAP chart for completeness?
find subjective complaints in the HPI and follow them through the rest of the chart (HPI, ROS, PE and/or results, assessment and plan)
HPI - content
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
A complete HPI contains the following elements: (hint: 8)
onset, timing, location, quality, severity, modifying factors, associated Sx, context
**the CC is not an element; the elements describe the CC!
HPI element: onset
when did the complaint begin?
HPI element: timing
has it been constant, intermittent, or waxing and waning?
HPI element: location
where is the discomfort?
HPI element: quality
does it feel sharp, dull, aching, cramping, etc.?
HPI element: severity
how bad is it? mild, moderate, severe, or 0-10?
HPI element: modifying factors
what makes it better? what makes it worse?
HPI element: associated Sx
do any other symptoms accompany the complaint?
HPI element: context
is there anything else that’s important?
