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

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-toe checklist of pt's symptoms) Intermittent comes and goes (start/stop) Waxing and waning always present but changing in intensity Modifying factor something that makes a symptom better or worse Exacerbate to make worse Attestation The scribe and providers sign off that the chart was prepared by a scribe then approved by provider SOAP Note Structure Subjective- info from the pt, includes CC, HPI, ROS Objective- info found by provider or clinical staff, includes vital signs, PE, test/imaging orders and results Assessment- the pt's diagnoses, and a short description of the progress since last visit Plan- follow-up and treatment plan for each diagnosis SOAP Note Sample Pic Subjective section always includes: -CC -HPI Session 3: SOAP Note- Subjective Section CHIEF COMPLAINT ALWAYS include CC, since EVERY level of billing req one in order for reimbursement Examples of non-reimbursable CCs and how to fix them ex. "check-up" --> 3 month diabetes management visit ex. "follow-up" --> HTN management evaluation ex. "lab results" --> discuss treatment options for elevated TSH ex. "medication refill" --> evaluation of medication management for HTN HISTORY OF PRESENT ILLNESS (HPI) What is it? -story of CC symptoms and events that led to the clinic visit -belongs at start of chart following CC -summarizes reason for visit -it is vital bc it is the basis for the entire workup that follows HPI Determines the Entire Visit HPI= abd pain x1 week ROS= positive abd pain PE= tenderness in the RUQ Orders= US (ultrasound) of the RUQ to evaluate abd pain Diagnosis= abd pain-->cholelithiasis (gallstones) Example of chart flow starting with CC 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 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 HPI contains ONLY... -Subjective info -info directly related to CC ALWAYS write the answers to the doctor's questions If your chart is missing the answer to a questions, there is no record of the doctor ever asking it HPI ELEMENTS!!! For pts that come in with symptoms similar to those they have experienced in the past, it is important to doc... -anything new or diff about their symptoms today -how long ago did the similar symptoms occur -did the pt seek professional treatment at that time -was there any result or Dx from previous evaluation HPI- PRIOR EVALUATION If the pt has had any prior testing related to his compaint, you must doc... -who ordered the test (Name and specialty) -specific name of the test (lab, XR, CT, MRI, etc) -date of the test -results -Dx given to the pt The 3 Primary Structure Types for Outpatient HPI 1- Single Complaint Formula 2- Multiple Complaint Formula 3-Chronologic (Complex Story) Single Complaint Formula -most commonly used -best for pts with only 1-2 complaints that have not been previously evaluated Single Complaint Formula Picture Single Complaint Example HPI Multiple Complaint Formula -commonly used in primary care OP -best for pts who: *have multiple complaints *routine follow-up for chronic illnesses *diff treatment plans for diff complaints Multiple Complaint Formula Picture 1 Multiple Complaint Formula Picture 2 Multiple Complaint Formula Picture 3 Chronologic (Complex Story) Formula Best for: -pts with multiple comorbidities -pts that have a significant workup in the past -established pts here for a follow-up of a chronic illness Chronologic (Complex Story) Structure Pic Chronologic (Complex Story) Example 1 Chronologic (Complex Story) Example 2 HPI PHRASING- DOs and DON'Ts (part 1) HPI PHRASING- DOs and DON'Ts (part 2) REVIEW OF SYSTEMS (ROS) Pic Which HPI structure should I use? Depends on: -specialty -clinic preference -provider preference -patient complexity -number of patient complaints ROS will contain the CC True! Four Types of ROS 1- Physician-led 2- Nurse-led 3- Pt Questionnaire 4- ROS statement refers to HPI Physician-led ROS -usually checklist style of +/- -doctor will review all body systems w the pt while scribe docs real-time -be ready to type quick!!! -only doc symptoms the doctor asks in order to avoid committing medical fraud!!! Nurse-led ROS -nurse performs ROS during their initial assessment, prior to physician entering room -scribe will be able to see the ROS in the EMR prior to starting doc -if you notice any diff between nurse's ROS and your HPI, bring it to doctors attention and ask if they want you to correct it with the nurse -common in OP settings Session 3: SOAP Note- Subjective Section ROS statement refers to HPI ROS -less common -"ROS per HPI, otherwise negative"