Lecture 3 Flashcards
SOAP
subjective
objective
assessment
plan
organizes clinical info in patient’s chart.
subjective
patient’s feelings
objective
facts
history of present illness
HPI: patient’s chief complaint
review of systems
ROS: head-to-toe checklist of patient’s symptoms
intermittent
comes and goes
wax / wane
always present but changing in intensity (flares, chronic)
modifying factor
something that makes symptoms better / worse
subjective section includes:
chief complaint
HPI
ROS
(also past Hx?)
objective section includes:
vital signs
PE
orders
results
assessment section includes:
short description of progress from last visit
plan section includes:
F/U
treatment plan for each Dx
chief complaint
main reason for visit - subjective
HPI
story of chief complaint (illness story) - subjective
ROS
checklist of symptoms for all body systems - subjective
subjective info comes from whom:
patient
parent / pediatric
son/daughter
caregiver
chief complaint - which level of billing requires
EVERY LEVEL for reimbursement
Which is most commonly used non-reimbursable chief complaint
“F/U”
What must you use instead of:
check-up
(illness) “maintenance visit”
What must you use instead of:
F/U
(illness) management evaluation
What must you use instead of:
lab results
treatment options (for illness)
What must you use instead of:
medication refill
medication management (of illness)
why it is important to include chief complaint on every chart:
so it’s billable
HPI includes info like …
- story of symptoms and events that lead to clinic visit
- at beginning of chart written by MA
- reason for visit summary
every subjective evaluation is followed by what kind of eval?
objective
how to check chart for completeness?
find the subjective complaints and follow them through the rest of your chart.
flow of HPI –> plan
HPI ROS PE Orders/results Assessment Plan
why is writing an accurate HPI important?
it’s the basis for the workup that follows
HPI only contains what?
- subjective info
2. info related to chief complaint (directly)
things you document:
answer to every specific Q the doc asks
HPI content
element onset timing location quality severity modifying factors associated Sx context
element
description
onset
when chief complaint began
timing
constant/intermittent/wax-wane
location
where discomfort is
quality
quality of pain – sharp, dull, aching, cramping
severity
how bad? mild, moderate, 0-10
modifying factors
what makes it better/worse
associated Sx
other symptoms accompany the complaint
context
anything else important (risk factors, anyone else sick)
evaluation for symptom experienced in past, important to document: (2)
- anything new / different
- how long ago symptoms occur
- did they seek treatment at time
- previous appt result/diagnoses
if pt had prior testing related to complaint, important to document: (4)
- who ordered test
- name of test (lab, CT, MRI)
- results
- Dx given
3 primary methods of structuring outpatient HPI
- single complaint formula
- multiple complaint formula (us)
- chronologic (complex)
single complaint formula
best for patients with 1-2 complaints that have not been previously evaluated
single complaint formula includes:
age + sex complaint / onset quality, timing, location modifying associated Sx / pertinent negatives context
need to know where all the sections of the HPI go and be able to name them in a paragraph (single complaint)
HPI formula:
- age / sex
- chief complaint / onset
- timing quality location
- modifying factors
- associated Sx
- context
multiple complaint formula
multiple complaints, routine F/U for chronic illness, different treatment plans for different complaints
(most often used for primary care)
multiple complaint formula includes
all the sections broken into paragraphs for each complaint
para 1: cough
para 2: HTN
para 3: diabetes
multiple complaint where sections go:
intro
para1: cough: onset, timing, modifying factors, etc.
para2: HTS: progress since last visit, med compliance, etc.
para3: headaches: onset, timing, modifying factors, etc.
chronologic:
complex story:
multiple comorbidities, significant workup in past, established chronic patient for F/U
precise order of events, evaluations, and symptoms
(important to get chronology right for complex stories)
chronologic structure:
- age/sex
- PMH2
- previous eval
- previous Tx
- current complaints
- elements of 1st complaint
- elements of 2nd complaint (etc.)
- context
general history —> “today, ….”
HPI structure depends on multiple factors:
speciality clinic preference provider preference patient complexity # of patient complaints
first step in all formals is:
age/sex
HPI phrasing
complete sentences
proper capitalization + punctuation
spelling
approved medical abbrev. (good! and write it out)
HPI phrasing Do/Don’t
use days since Sx started
don’t use “got” ==> “worsened by palpitation … “
vary beginning of sentences
describe specific Sx affecting pt “flu-like symptoms”
document only things that are relevant to today’s complaint.
R?OS:
phrased in simple list of positives and negatives + / -
includes Sx in HPI
no story / context placed here
must never contradict HPI b/c they are subjective
constitutional
fever, weight loss, sweats
eyes
vision, eye pain, double vision
ENT
ear ache, nose bleed, sore throat
cardiovascular
chest paint, palpitations
respiratory
SOB, cough, wheeze
gastrointestinal
abd pain, NVD, black stools
genitourinary
dysuria, frequency
musculoskeletal
joint pain, muscle pain
integumentary / skn
rash, itching, abrasion, laceration
neurological
headache, syncope, numbness
psych
depression/anxiety
endocrine
polyuria, polydipsia
hemotologic/lymph
bleeding gums, easy bruising, swollen lymph nodes
immunologic
HIV / AIDs
physician lead ROS
physician reviews all body systems and scribe documents in realtime.
- type quickly
- docs type fast
- EHRs have check boxes and template lists of Sx. – avoid medical fraud
