scribe 101 - charting Flashcards
1
Q
SOAP
A
subjective, objective, assessment, plan
2
Q
4 parts of subjective
A
CC, HPI, ROS, Past history
3
Q
parts if a HPI
A
CC, onset, timing(constant, intermittent, waxing/waning) location, quality (sharp, dull….), severity, modifying factors, associated symptoms, context
4
Q
ROS
A
must include what’s in the HPI
5
Q
CC
A
chief complaint
6
Q
Pt
A
patient
7
Q
c/o
A
complains of
8
Q
y/o
A
year old
9
Q
c
A
without
10
Q
s
A
with
11
Q
runny nose
A
rhinorrhea
12
Q
throwing up
A
emesis, vomiting
