SOAP Flashcards
intermittent
comes and goes
waxing and waning
always present but changing in intensity
modifying factor
something that makes a symptom better or worse
exacerbate
to make worse
attestation
the scribe and providers sign off that the chart was prepared by a scribe then approved by provider
where does subjective information come from?
the patient
parents
caretakers
son/daughter
what is included in the subjective information
CC, HPI, ROS,
Every level of billing requires a what ?
chief complaint
HPI contains only what?
subjective info and ONLY reveant info directed to the chief complaint
what are the 8 elements of the HPI?
onset timing location quality severity modifcation factors associated Sx context
what do you ask if a patient has had similar Sx in the past ?
anything new or different about their symptoms today?
how long ago did the simialr symptoms occur?
did the Pt seek professional treatment?
was there any result or diagnoses from previous evaluation?
what do you ask if they had prior evaluation?
who ordered the test what test date of test results diagnoses
when is it okay to use a single complaint formulat in the HPI?
for patients with only 1-2 complaints that have not been previously evaluated
when is it okay to use a multiple complaint formula?
used in primary care or internal medicine OP practice
effective for patients who have
multiple complaints
routine follow up for chronic illnesses
different tx plans for different complaints
when is it okay to use a chronological structure in the HPI? (Complex story)
patients with multiple comorbidities
patients who have had a significant work up in the past
established pts here for follow up of a chronic illness
