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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what information goes into the objective portion of a SOAP note?

A

exam
labs/diagnostic tests

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what is a MTR?

A

medication therapy review: reviews patient-specific inforamation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what is a PMR?

A

personal medication record

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what is a MAP?

A

medication-related action plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly