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
What is the plan section in SOAP notes?
A list outlining how the provider will treat and/or monitor the patient
How is the plan section of the SOAP notes laid out?
Listed in bullets, numbers, or spacing
What aspects should be included in the plan? (5)
Recommended treatments for each diagnosis
Prescriptions ordered
Studies, tests, labs, and/or imagine ordered
Follow-up with another health care professional (who and when?)
Follow-up here (when?)
When/where/how is the plan section written up?
In the room with the patient, usually dictated verbatim by physician.
What does MACRA stand for?
Medicare Access and CHIP Reauthorization Act
What does CMS stand for?
Centers for Medicare & Medicaid Services
What does MIPS stand for?
Merit-based Incentive Payment System
What does CPOE stand for?
Computerized Physician Order Entry
What is the function of MACRA? When did it begin?
Merit-based payment model for physicians run by CMS; began Jan 1, 2017
Provider is paid more for better quality of care and improved outcomes
