Session 3: SOAP Note- Subjective Section
1. SOAP Subjective
Objective
Assessment
Plan
2. Subjective Based on pts feelings (HPI, ROS)
3. Objective Factual info from the provider (PE)
4. HPI History of Present Illness (the sotry of the pts CC)
5. ROS Review of Systems (head-to-toe checklist of pt's symp-
toms)
6. Intermittent comes and goes (start/stop)
7. Waxing and wan- always present but changing in intensity
ing
8. Modifying factor something that makes a symptom better or worse
9. Exacerbate to make worse
10. Attestation The scribe and providers sign off that the chart was pre-
pared by a scribe then approved by provider
11. SOAP Note Subjective- info from the pt, includes CC, HPI, ROS
Structure
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
12. SOAP Note Sam-
ple Pic
1/7
, Session 3: SOAP Note- Subjective Section
Study online at https://quizlet.com/_6wo53m
13. Subjective sec- -CC
tion always in- -HPI
cludes: -ROS
14. CHIEF COM- ALWAYS include CC, since EVERY level of billing req one
PLAINT in order for reimbursement
15. Examples of ex. "check-up" --> 3 month diabetes management visit
non-reim-
bursable CCs ex. "follow-up" --> HTN management evaluation
and how to fix
them ex. "lab results" --> discuss treatment options for elevated
TSH
ex. "medication refill" --> evaluation of medication man-
agement for HTN
16. HISTORY OF -story of CC symptoms and events that led to the clinic
PRESENT ILL- visit
NESS (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
17. HPI Determines HPI= abd pain x1 week
the Entire Visit
ROS= positive abd pain
PE= tenderness in the RUQ
Orders= US (ultrasound) of the RUQ to evaluate abd pain
Diagnosis= abd pain-->cholelithiasis (gallstones)
18. Example of chart CC+HPI=
flow starting with pt c/o sore throat x2 days with intermittent fever reaching
CC 101.2. She denies difficulty swallowing
ROS=
+sore throat
2/7
1. SOAP Subjective
Objective
Assessment
Plan
2. Subjective Based on pts feelings (HPI, ROS)
3. Objective Factual info from the provider (PE)
4. HPI History of Present Illness (the sotry of the pts CC)
5. ROS Review of Systems (head-to-toe checklist of pt's symp-
toms)
6. Intermittent comes and goes (start/stop)
7. Waxing and wan- always present but changing in intensity
ing
8. Modifying factor something that makes a symptom better or worse
9. Exacerbate to make worse
10. Attestation The scribe and providers sign off that the chart was pre-
pared by a scribe then approved by provider
11. SOAP Note Subjective- info from the pt, includes CC, HPI, ROS
Structure
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
12. SOAP Note Sam-
ple Pic
1/7
, Session 3: SOAP Note- Subjective Section
Study online at https://quizlet.com/_6wo53m
13. Subjective sec- -CC
tion always in- -HPI
cludes: -ROS
14. CHIEF COM- ALWAYS include CC, since EVERY level of billing req one
PLAINT in order for reimbursement
15. Examples of ex. "check-up" --> 3 month diabetes management visit
non-reim-
bursable CCs ex. "follow-up" --> HTN management evaluation
and how to fix
them ex. "lab results" --> discuss treatment options for elevated
TSH
ex. "medication refill" --> evaluation of medication man-
agement for HTN
16. HISTORY OF -story of CC symptoms and events that led to the clinic
PRESENT ILL- visit
NESS (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
17. HPI Determines HPI= abd pain x1 week
the Entire Visit
ROS= positive abd pain
PE= tenderness in the RUQ
Orders= US (ultrasound) of the RUQ to evaluate abd pain
Diagnosis= abd pain-->cholelithiasis (gallstones)
18. Example of chart CC+HPI=
flow starting with pt c/o sore throat x2 days with intermittent fever reaching
CC 101.2. She denies difficulty swallowing
ROS=
+sore throat
2/7
