Scribe America Outpatient Course 3
Exam Questions with Correct Answers
SOAP - Answer-subjective, objective, assessment, plan
subjective - Answer-based on the patient's feeling (HPI and ROS)
Objective - Answer-Factual information from provider (PE)
History of Present Illness
(1 simple def) - Answer-The story of the patient's chief complaint
Review of Systems - Answer-Head to toe checklist of patient's symptoms
intermittent - Answer-comes and goes
waxing and waning - Answer-always present but changing in intensity
modifying factor - Answer-something that makes a symptom better or worse
exacerbate - Answer-to make worse (make symptoms worse)
Attestation - Answer-The scribe and providers sign off that the chart was prepared by a
scribe then approved by provider
S.O.A.P note- definition - Answer-- is a method of organizing clinical information in a
patient's chart.
- It closely follows the workflow of the clinic so that each portion of the SOAP note is
documented consecutively as information is obtained from the patient
What portions of the (SOAP) chart does the Subjective structure include (3) - Answer-
information from the patient
1. Chief Complaints
2. HPI
3. ROS
What portions of the (SOAP) chart does the Objective structure include (4) - Answer-
information from the provider
1. vital signs
2. PE
, 3. Orders
4. Results
What portions of the (SOAP) chart does the Assessment structure Include? (1) -
Answer-the patient's diagnoses
1. A short description of progress since last visit
What portions of the (SOAP) chart does the Plan structure Include? (2) - Answer-follow
up and treatment plan for each diagnosis
SOAP note structure (all 7 pieces in it + def) - Answer-1. History of Present illness: the
story and context of chief complaint
2. Review of Systems (ROS): a checklist of pertinent positives and negatives
3. Past history (PMSHx, SHx, FHx): past disease/surgeries, ETOH/Tobacco, FHx
4. Physical Examination (PE): the provider's objective finding
5. Orders and Results
6. Assessments: diagnoses
7. plan: treatment and follow up
T/F the structure of the SOAP note closely follows the clinic flow - Answer-True
T/F you will usually document the assessment before documenting the HPI - Answer-
False
What are the two components of the subjective assessment? - Answer-HPI and ROS
Three main details of the Subjective information - Answer-1. subjective infor comes
directly from the person giving the history
- in most cases, the patient
- possibly a parent for pediatric patients
-possibly a son/daughter for elderly patients
2. subjective information is the first item the physician discusses with the patient upon
entering the room
3. Subjective information is the first section the scribe documents in the chart
Which portion of the SOAP note contains the results of orders? - Answer-the Objective
part contains PE and orders and results
Exam Questions with Correct Answers
SOAP - Answer-subjective, objective, assessment, plan
subjective - Answer-based on the patient's feeling (HPI and ROS)
Objective - Answer-Factual information from provider (PE)
History of Present Illness
(1 simple def) - Answer-The story of the patient's chief complaint
Review of Systems - Answer-Head to toe checklist of patient's symptoms
intermittent - Answer-comes and goes
waxing and waning - Answer-always present but changing in intensity
modifying factor - Answer-something that makes a symptom better or worse
exacerbate - Answer-to make worse (make symptoms worse)
Attestation - Answer-The scribe and providers sign off that the chart was prepared by a
scribe then approved by provider
S.O.A.P note- definition - Answer-- is a method of organizing clinical information in a
patient's chart.
- It closely follows the workflow of the clinic so that each portion of the SOAP note is
documented consecutively as information is obtained from the patient
What portions of the (SOAP) chart does the Subjective structure include (3) - Answer-
information from the patient
1. Chief Complaints
2. HPI
3. ROS
What portions of the (SOAP) chart does the Objective structure include (4) - Answer-
information from the provider
1. vital signs
2. PE
, 3. Orders
4. Results
What portions of the (SOAP) chart does the Assessment structure Include? (1) -
Answer-the patient's diagnoses
1. A short description of progress since last visit
What portions of the (SOAP) chart does the Plan structure Include? (2) - Answer-follow
up and treatment plan for each diagnosis
SOAP note structure (all 7 pieces in it + def) - Answer-1. History of Present illness: the
story and context of chief complaint
2. Review of Systems (ROS): a checklist of pertinent positives and negatives
3. Past history (PMSHx, SHx, FHx): past disease/surgeries, ETOH/Tobacco, FHx
4. Physical Examination (PE): the provider's objective finding
5. Orders and Results
6. Assessments: diagnoses
7. plan: treatment and follow up
T/F the structure of the SOAP note closely follows the clinic flow - Answer-True
T/F you will usually document the assessment before documenting the HPI - Answer-
False
What are the two components of the subjective assessment? - Answer-HPI and ROS
Three main details of the Subjective information - Answer-1. subjective infor comes
directly from the person giving the history
- in most cases, the patient
- possibly a parent for pediatric patients
-possibly a son/daughter for elderly patients
2. subjective information is the first item the physician discusses with the patient upon
entering the room
3. Subjective information is the first section the scribe documents in the chart
Which portion of the SOAP note contains the results of orders? - Answer-the Objective
part contains PE and orders and results
