OP Course 1: CC/HPI/ROS - Subjective

Question 1

What are the three components of the subjective portion of SOAP notes?

Answer 1

Chief complaint (CC)
History of present illness (HPI)
Review of systems (ROS)

Question 2

What is the function of HPI?

Answer 2

Story of symptoms and events leading to clinic visit; builds off the chief complaint

Question 3

What is the function of the ROS?

Answer 3

Head-to-toe checklist of the entire body (+, -, or not addressed); not limited to HPI

Question 4

What is the function of the CC? Why is it required?

Answer 4

Primary reason that brought the patient to the clinic

• legally required
• required for billing

Question 5

What is a way to rephrase “check-up” to make it a reimbursable term in the CC?

Answer 5

3 month diabetes management

Question 6

What is a way to rephrase “follow-up” to make it a reimbursable term in the CC?

Answer 6

HTN management evaluation

Question 7

What is a way to rephrase “lab results” to make it a reimbursable term in the CC?

Answer 7

Discuss treatment options for elevated TSH

Question 8

What is a way to rephrase “medication refill” to make it a reimbursable term in the CC?

Answer 8

Evaluation of medication management for HTN

Question 9

What is a way to rephrase “annual check-up” to make it a reimbursable term in the CC?

Answer 9

Wellness exam

Question 10

What are the 8 elements of the HPI?

Answer 10

1. Onset
2. Timing
3. Location
4. Quality
5. Severity
6. Modifying factors
7. Associated symptoms & pertinent negatives
8. Context

Question 11

What does “onset” refer to in the HPI?

Answer 11

When symptoms began

Question 12

What does “timing” refer to in the HPI?

Answer 12

Constant? Intermittent? Waxing & waning?

Question 13

What does “location” refer to in the HPI?

Answer 13

Where pain or complaint is located

Question 14

What does “quality” refer to in the HPI?

Answer 14

Sharp? Dull? Throbbing? Burning?

Question 15

What does “severity” refer to in the HPI?

Answer 15

Mild? Moderate? Severe? 1-10?

Question 16

What does “modifying factors” refer to in the HPI?

Answer 16

Do certain things make it better or worse? What have they tried?

Question 17

What are “associated symptoms” and “pertinent negatives”?

Answer 17

Associated symptoms: symptoms that accompany the chief complaint?

Pertinent negatives: Important symptoms that are not present (ex: CC of chest pain, negative for SOB)

Question 18

What does “context” refer to in the HPI?

Answer 18

Any other information (ex: testing, previous Dx, etc.)

Question 19

What is a good formula to follow for a single complaint HPI? (6)

Answer 19

1. Age & sex
2. Complaint & onset
3. Quality, timing, & location
4. Modifying factors
5. Associated symptoms & pertinent negatives
6. Context

Question 20

How should you set up a chronologic formula HPI for multiple chief complaints?

Answer 20

Age/sex –> relevant PMHx –> Previous evaluation –> Previous treatment –> Current CC(s) –> Element of CC1 –> Element of CC2…3…4 –> Context

Question 21

What is an example of a good intro phrase to start a HPI?

Answer 21

Pt is a 36 y/o male…last seen…

Question 22

What is a physician-led ROS?

Answer 22

ROS is filled out by scribe in the room with physician and patient

Question 23

What is a nurse-led ROS?

Answer 23

Nurse performs ROS on their own; should still be checked for errors by scribe

Question 24

What is a ROS statement?

Answer 24

Short sentence that refers the ROS to the HPI (rare); should make HPI more detailed

Ex: “ROS per HPI, otherwise negative”