Interviewing and Documentation Flashcards
1
Q
What information goes into the subjective portion of a SOAP note?
A
chief complaint
allergies
history of present illness
past medical history
family history
social history
review of symptoms
2
Q
what information goes into the objective portion of a SOAP note?
A
exam
labs/diagnostic tests
3
Q
what is a MTR?
A
medication therapy review: reviews patient-specific inforamation
4
Q
what is a PMR?
A
personal medication record
5
Q
what is a MAP?
A
medication-related action plan
6
Q
what are the 7 attributes of a symptom? (LQQ/STORA)
A
location
quality
quantity/severity
timing
onset
remitting or exacerbating factors
associated manifestations