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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, ordR148,79
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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
WELL AP - WELL Accredited Professional
Institution
WELL AP - WELL Accredited Professional
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...
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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