SOAP Basics Flashcards
SOAP
subjective, objective, assessment, plan
subjective
based on the patient’s feelings
HPI and ROS
objective
factual information from provider (PE)
history of present illness
story of patient’s chief complaint (CC)
paragraph form
HPI
review of systems
head-to-toe checklist of patient’s symptoms
ROS
intermittent
comes and goes
type of timing
waxing and waning
always present but changing in intensity
type of timing
modifying factor
something that makes a symptom better or worse
exacerbate
to make worse
type of modifying factor
attestation
the scribe and providers sign off that the chart was prepared by a scribe and approved by provider
chief complaint
main reason for visit
CC
required
elements of HPI
onset, timing, location, quality, severity, modifying factors, associated symptoms, context
O T L Q S M AS C
elements of HPI
onset, timing, location, quality, severity, modifying factors, associated symptoms, context
onset
when did the complaint begin
timing
is the issue constant, intermittent, or waxing and waning
