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

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 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 S.O.A.P. note a method of organizing clinical information in a patient's chart; follows the workflow of the clinic assessment the patient's diagnoses; a short description of progress plan follow-up and treatment for each diagnosis chief complaint the reason the patient is there, always include in notes, every level of billing requires a chief complaint, be specific about the reason for the visit! history of present illness story of symptoms that led to clinic visit, summarizes reason for visit, forms basis for workup subjective complaints can be followed through the entirety of the chart, in all of the sections HPI content only subjective information related to the chief complaint; every question the doctor asks is important, so record them! HPI elements 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, 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 prior evaluation who ordered the test (name and specialty), specific name of the test, date, results, diagnosis HPI structure single complaint formula, multiple complaint formula, chronologic single complaint formula commonly used, best with only 1 or 2 complaints; age and sex, complaint and onset, quality, timing, location, modifying factors, associated symptoms, pertinent negatives, other important context multiple complaint formula used in primary care or internal medicine OP, good for patients with multiple complaints, routine follow-up, different treatment plans for different complaints; each complaint or disease is documented in a separate paragraph chronologic (complex story) patients with multiple comorbidities, significant workup in the past, established patients here for follow-up; age and sex, relevant PMHx, previous evaluation, previous treatment, current complaint(s), elements of first complaint, elements of second complaint, context HPI phrasing write in complete sentences, proper grammar, check spelling, only use approved medical abbreviations ROS phrased as a simple list of positives and negatives, includes all symptoms experienced, no story or context used, and must not contradict the HPI physician-led ROS physician reviews all body systems with the patient in real-time; only document the symptoms the doctor asks about in order to avoid committing medical fraud nurse-led ROS nurse performs full ROS before physician enters; scribe can see this in the EMR patient questionnaire ROS usually done for a first-time visit, patient fills out checklist in the waiting room ROS refers to HPI much less common; only if EMR does not have a space for a separate ROS