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Course 3: The S.O.A.P. Note - Subjective Terms in this set (29) SOAP subjective, objective, assessment, plan subjective based on the patient's feeling (chief complaint, HPI, ROS) objective factual information from provider (PE, vital signs, ord $7.99
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Course 3: The S.O.A.P. Note - Subjective Terms in this set (29) SOAP subjective, objective, assessment, plan subjective based on the patient's feeling (chief complaint, HPI, ROS) objective factual information from provider (PE, vital signs, ord
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Course 3: The S.O.A.P. Note - Subjective Terms in this set (29) SOAP subjective, objective, assessment, plan subjective based on the patient's feeling (chief complaint, HPI, ROS) objective factual information from provider (PE, vital signs, orders, results) history of present ill...

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  • August 11, 2024
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  • 2024/2025
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  • course 3 the soap note subjective te

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  • WELL AP - WELL Accredited Professional
  • WELL AP - WELL Accredited Professional

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8/11/24, 1:45 AM



Course 3: The S.O.A.P. Note - Subjective
Jeremiah




Terms in this set (29)

SOAP subjective, objective, assessment, plan

subjective based on the patient's feeling (chief complaint, HPI, ROS)

objective factual information from provider (PE, vital signs, orders, results)

history of present illness (HPI) the story of the patient's chief complaint

review of systems (ROS) head-to-toe checklist of patient's symptoms

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

a method of organizing clinical information in a patient's chart; follows the workflow of
S.O.A.P. note
the clinic

assessment the patient's diagnoses; a short description of progress

plan follow-up and treatment for each diagnosis

the reason the patient is there, always include in notes, every level of billing requires a
chief complaint
chief complaint, be specific about the reason for the visit!

story of symptoms that led to clinic visit, summarizes reason for visit, forms basis for
history of present illness
workup

subjective complaints can be followed through the entirety of the chart, in all of the sections

only subjective information related to the chief complaint; every question the doctor
HPI content
asks is important, so record them!

onset - when did the complaint begin? timing - has it been constant, intermittent, or
waxing and waning? location - where is the discomfort? quality - does it feel sharp,
HPI elements dull, aching, cramping...? severity - mild, moderate, severe 0-10? modifying factors -
what makes it better or worse? associated Sx - do other symptoms accompany the
complaing? context - is there anything else that's important?

document anything new, how long ago were previous symptoms, did patient receive

Course 3: The S.O.A.P. Note - Subjective




HPI similar symptoms previously
treatment then and what were the results



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