S.O.A.P Note Subjective (Outpatient Pre-
clinical Training Course 3) Questions with
Complete
verified Solutions
What are the 3 items that are included in the subjective evaluation? - ANSWER CC, HPI, ROS
What is a chief complaint? - ANSWER the primary reason that brought the patient to the clinic
______ include a chief complaint - ANSWER ALWAYS
______ level of billing requires a CC in order to be reimbursed for the service provided -
ANSWER EVERY
Reimbursable or Non-Reimbursable?: Check-Up - ANSWER Non-Reimbursable
Reimbursable or Non-Reimbursable?: HTN management evaluation - ANSWER Reimbursable
Reimbursable or Non-Reimbursable?: Follow-UP - ANSWER Non-Reimbursable
Reimbursable or Non-Reimbursable? Discuss treatment options for elevated TSH - ANSWER
Reimbursable
, Reimbursable or Non-Reimbursable?: Lab Results - ANSWER Non-Reimbursable
Reimbursable or Non-Reimbursable?: Evaluation of medication management for HTN - ANSWER
Reimbursable
Reimbursable or Non-Reimbursable?: Medication Refill - ANSWER Non-Reimbursable
Why is it important to include a chief complaint on every chart? - ANSWER So physician get
reimbursed
Fix the CC to make it billable:
Results of bloodwork (low hemoglobin) - ANSWER Discuss treatment options for anemia
Fix the CC to make it billable:
HTN follow-up - ANSWER HTN management evaluation
Fix the CC to make it billable:
Refill of Lisinopril - ANSWER Evaluation & management of Lisinopril
Fix the CC to make it billable:
Check-up - HLD - ANSWER Maintenance visit of HLD
What are the three factors that make up the history of present illness? - ANSWER - the story of
symptoms and events that led to the clinic visit
- belongs at the beginning of the chart immediately following the chief complaint
- summarizes the reason for the visit
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