ppt Flashcards
What is a SOAP note?
A note used to document patient encounters
Not a full H & P
What are SOAP notes used for?
Used for:
Ambulatory Care Settings
Problem Specific Visits
Daily Hospital Progress Notes
What does SOAP stand for?
S- Subjective
O- Objective
A- Assessment
P- Plan
What is the subjective component?
Information that the patient tells you
How do you obtain the subjective component?
The patient OR sometimes: Spouse Family Member Caregiver Nurses Other healthcare providers Prior Medical Records (but only some of the prior medical record)
What form should the subjective info be in?
Most of this should be narrative (there are a few exceptions) CC HPI Pertinent FH Pertinent ROS Pertinent PMH Pertinent SH Allergies Medications
Unless pertinent to the HPI which are not narrative?
Allergies
Medications
What all do you need to make sure you include?
Onset/Duration Location Character Severity Associated signs/symptoms Aggravating/Alleviating factors
Do you have any spaces in subjective?
NO
What is involved in the objective portion?
What you see or observe first hand
What is the best way to do the objective portion?
organ system
What do you include in the objective?
The best, and most accepted way to do this is by organ system
VS Gen Derm HEENT CV Chest Abd GU Musc/Skel Neuro
Diagnostic Tests
Interventions Done During Visit
What is the assessment portion?
This is where your diagnosis (ses) are placed
You can do a presumptive diagnosis
Example- Right adnexal pain
What is your assessment based on?
Based on your analysis of S and O
What do you not use in the assessment portion?
Rule Out
What is the assessment the same as?
Problems list
Can you use a ddx in your assessment?
Yes
How do you present a Ddx in your assessment portion?
Must be CLEARLY specified
DDX should be listed in order of likelihood
What should your first diagnosis represent?
CC
When do you document the existing comorbidities?
Each visit
What are key things to keep in mind when writing your assessment?
Use medical terms and be as descriptive as possible
What is the ICD 10?
International classification of disease
What is the ICD 10 used for?
Often used to determine reimbursement
What do your codes need to justify?
Your codes need to justify tests that you order
What types of codes should you use?
Use the most specific code you know
What goes into the Plan portion?
This is where you establish your plan of care.
Each diagnosis in the assessment must be addressed here
What do you need to make sure you include in the Plan portion?
Make sure to include: Tests and referrals Drugs Patient Education Follow up instructions
What do you need to keep in mind for with drugs and prescriptions?
With drugs give always include dosage, mode, etc
w/ prescriptions same but also how many refills etc
What do you do if the patient has a problem that could be symmetrical?
If the patient has a problem that could be symmetrical, always document the other side.
What are the principals of charting?
Use Permanent Ink Date and Time Sign Your Notes (And sup. doc to sign) Legible! Do not alter an entry No scratch outs or white out No late entries No blank lines Do not use unapproved abbreviations
