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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 CCR148,49
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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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WELL AP - WELL Accredited Professional
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WELL AP - WELL Accredited Professional
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...
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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