ppt

Question 1

What is a SOAP note?

Answer 1

A note used to document patient encounters

Not a full H & P

Question 2

What are SOAP notes used for?

Answer 2

Used for:
Ambulatory Care Settings
Problem Specific Visits
Daily Hospital Progress Notes

Question 3

What does SOAP stand for?

Answer 3

S- Subjective
O- Objective
A- Assessment
P- Plan

Question 4

What is the subjective component?

Answer 4

Information that the patient tells you

Question 5

How do you obtain the subjective component?

Answer 5

The patient OR sometimes: 
Spouse
Family Member
Caregiver
Nurses
Other healthcare providers
Prior Medical Records (but only some of the prior medical record)

Question 6

What form should the subjective info be in?

Answer 6

Most of this should be narrative (there are a few exceptions)
CC
HPI
Pertinent FH
Pertinent ROS
Pertinent PMH
Pertinent SH
Allergies
Medications

Question 7

Unless pertinent to the HPI which are not narrative?

Answer 7

Allergies

Medications

Question 8

What all do you need to make sure you include?

Answer 8

Onset/Duration
Location
Character
Severity
Associated signs/symptoms
Aggravating/Alleviating factors

Question 9

Do you have any spaces in subjective?

Answer 9

NO

Question 10

What is involved in the objective portion?

Answer 10

What you see or observe first hand

Question 11

What is the best way to do the objective portion?

Answer 11

organ system

Question 12

What do you include in the objective?

Answer 12

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

Question 13

What is the assessment portion?

Answer 13

This is where your diagnosis (ses) are placed
You can do a presumptive diagnosis
Example- Right adnexal pain

Question 14

What is your assessment based on?

Answer 14

Based on your analysis of S and O

Question 15

What do you not use in the assessment portion?

Answer 15

Rule Out

Question 16

What is the assessment the same as?

Answer 16

Problems list

Question 17

Can you use a ddx in your assessment?

Answer 17

Yes

Question 18

How do you present a Ddx in your assessment portion?

Answer 18

Must be CLEARLY specified

DDX should be listed in order of likelihood

Question 19

What should your first diagnosis represent?

Answer 19

CC

Question 20

When do you document the existing comorbidities?

Answer 20

Each visit

Question 21

What are key things to keep in mind when writing your assessment?

Answer 21

Use medical terms and be as descriptive as possible

Question 22

What is the ICD 10?

Answer 22

International classification of disease

Question 23

What is the ICD 10 used for?

Answer 23

Often used to determine reimbursement

Question 24

What do your codes need to justify?

Answer 24

Your codes need to justify tests that you order

Question 25

What types of codes should you use?

Answer 25

Use the most specific code you know

Question 26

What goes into the Plan portion?

Answer 26

This is where you establish your plan of care.

Each diagnosis in the assessment must be addressed here

Question 27

What do you need to make sure you include in the Plan portion?

Answer 27

Make sure to include:
Tests and referrals
Drugs
Patient Education
Follow up instructions

Question 28

What do you need to keep in mind for with drugs and prescriptions?

Answer 28

With drugs give always include dosage, mode, etc

w/ prescriptions same but also how many refills etc

Question 29

What do you do if the patient has a problem that could be symmetrical?

Answer 29

If the patient has a problem that could be symmetrical, always document the other side.

Question 30

What are the principals of charting?

Answer 30

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