OP Course 3: Assessment and Plan Flashcards
What should the “assessment” section of the SOAP notes contain?
Diagnoses (and/or differentials)
Summary of visit
What should be included in the summary of visit? (4)
Brief summary of HPI (CC & onset)
Brief summary of PE (pertinent findings only)
Summary of lab/imaging (if new since last visit)
Prognosis or justification for further testing or medication
T/F: When reviewing a previous visit, the physician is more likely to review HPI than assessment because the HPI is more comprehensive.
False
T/F: A diagnosis or differential diagnosis will always be listed in the assessment
True
What is included in the simple statement structure for an assessment? (3)
Age/sex
PMHx if relevant
Diagnoses
Diagnosis is _____ and summary is ______.
Mandatory or optional?
Diagnosis = mandatory
Summary = optional
What should be included in a brief summary structure of an assessment? (6)
Age/sex
PMHx if relevant
PE findings if relevant
Results, if new and relevant
Diagnoses
Differentials if no definitive diagnosis
What should be included in a comprehensive summary of an assessment? (7)
Age/sex
Summary of PMHx
Summary of PE
Summary of results
Diagnoses
Differentials if applicable
Prognosis if applicable
T/F: The assessment is typically written in complete sentences.
True
Does the assessment always being with the age & sex of the patient?
Yes
Results summary includes _______? (2)
Labs
Imaging
Where are results included in the chart?
All in objective
Relevant results in assessment
What is the difference between pertinent positive and pertinent negative results?
Positive: results confirming a diagnosis (ex: XR confirms fracture)
Negative: results that rule out a diagnosis (ex: negative strep test)
What should be included when summarizing test results? (3)
Name of test
Result of test
Why test was ordered?
T/F: The scribe should only include results that are new since last visit
True
