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Session 3: SOAP Note- Subjective Section Terms in this set (45) SOAP Subjective Objective Assessment Plan Subjective Based on pts feelings (HPI, ROS) Objective Factual info from the provider (PE) HPI History of Present Illness (the sotry of the pts CC $7.99
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Session 3: SOAP Note- Subjective Section Terms in this set (45) SOAP Subjective Objective Assessment Plan Subjective Based on pts feelings (HPI, ROS) Objective Factual info from the provider (PE) HPI History of Present Illness (the sotry of the pts CC
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Session 3: SOAP Note- Subjective Section Terms in this set (45) SOAP Subjective Objective Assessment Plan Subjective Based on pts feelings (HPI, ROS) Objective Factual info from the provider (PE) HPI History of Present Illness (the sotry of the pts CC) ROS Review of Systems (head-to-t...

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  • August 11, 2024
  • 5
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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8/11/24, 1:47 AM



Session 3: SOAP Note- Subjective Section
Jeremiah
Terms in this set (45)

Subjective
Objective
SOAP
Assessment
Plan

Subjective Based on pts feelings (HPI, ROS)

Objective Factual info from the provider (PE)

HPI History of Present Illness (the sotry of the pts CC)

ROS Review of Systems (head-to-toe checklist of pt's symptoms)

Intermittent comes and goes (start/stop)

Waxing and waning always present but changing in intensity

Modifying factor something that makes a symptom better or worse

Exacerbate to make worse

The scribe and providers sign off that the chart was prepared by a scribe then
Attestation
approved by provider

Subjective- info from the pt, includes CC, HPI, ROS


Objective- info found by provider or clinical staff, includes vital signs, PE, test/imaging
orders and results
SOAP Note Structure

Assessment- the pt's diagnoses, and a short description of the progress since last visit


Plan- follow-up and treatment plan for each diagnosis



SOAP Note Sample Pic



-CC
Subjective section always includes: -HPI

Session 3: SOAP Note- Subjective Section




-ROS



1/5

, 8/11/24, 1:47 AM
CHIEF COMPLAINT ALWAYS include CC, since EVERY level of billing req one in order for reimbursement

ex. "check-up" --> 3 month diabetes management visit


ex. "follow-up" --> HTN management evaluation
Examples of non-reimbursable CCs and how
to fix them
ex. "lab results" --> discuss treatment options for elevated TSH


ex. "medication refill" --> evaluation of medication management for HTN

-story of CC symptoms and events that led to the clinic visit
HISTORY OF PRESENT ILLNESS (HPI) -belongs at start of chart following CC
What is it? -summarizes reason for visit
-it is vital bc it is the basis for the entire workup that follows

HPI= abd pain x1 week


ROS= positive abd pain


HPI Determines the Entire Visit PE= tenderness in the RUQ


Orders= US (ultrasound) of the RUQ to evaluate abd pain


Diagnosis= abd pain-->cholelithiasis (gallstones)

CC+HPI=
pt c/o sore throat x2 days with intermittent fever reaching 101.2. She denies difficulty
swallowing


ROS=
+sore throat
-diff swallowing
+fever


PE=
ENT --> Bilateral tonsillar hypertrophy, pharyngeal erthyema, cervical
lymphadenopathy
Example of chart flow starting with CC
Vital signs--> Temp 100.8


Orders/Results=
Rapid strep test-->positive


Assessment=
1-Strep pharyngitis
2-fever


Plan=
1-take Abx as prescribed for strep
2-alternate tylenol/motrin for fever

-Subjective info
HPI contains ONLY...
-info directly related to CC

ALWAYS write the answers to the doctor's If your chart is missing the answer to a questions, there is no record of the doctor ever
questions asking it




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