ScribeAmerica: Outpatient Pre-Clinical
Training- Course 5: The S.O.A.P. Note -
Assessment and Plan(100% Correct)
Diagnosis - ANSWERSWhat the physician has determined to be the most likely cause
of the patient's symptoms
Assessment - ANSWERSA list of the patient's current diagnoses
Plan - ANSWERSThe currently laid out course of action to address the patient's
condition
Prognosis - ANSWERSA forecast of the likely course of a disease or ailment
Follow-up - ANSWERSOn-going contact with healthcare providers in order to address a
health concern
Diagnosis + Summary of visit = - ANSWERSAssessment
Assessment always includes... - ANSWERSDiagnosis: and/or differentials
Assessment may also include: - ANSWERS- Brief summary of the HPI: Typically chief
complaint and onset only
- Brief summary of physical exam: Pertinent findings only
- Summary of lab/imaging results: If new since the last visit
- Prognosis: Or justification for further testing or medication
T/F: When reviewing a previous visit, the physician is more likely to review the HPI than
the assessment because the HPI is more comprehensive - ANSWERSFalse
T/F: A diagnosis or differential diagnoses will always be listed in the assessment -
ANSWERSTrue
What are 3 items besides the diagnosis that may be documented in the assessment? -
ANSWERSBrief summary of HPI, Summary of PE, Summary of lab/imaging results
Assessment Structures (3) - ANSWERS- Simple Statement
- Brief Summary
- Comprehensive
The assessment is typically written in complete sentences.
, Simple Statement (3) - ANSWERS- Age and sex of patient
- Past medical history only if relevant
- Diagnoses
Brief Summary (6) - ANSWERS- Age and sex of patient
- Past medical history, if relevant
- Physical exam findings, if relevant
- Results, if new and relevant
- Diagnoses
- Differential, if no definitive diagnosis is found
Comprehensive Summary (9) - ANSWERS- Age and sex of patient
- Summary of PMHx
- Summary of HPI, including CC, onset, and important elements
- Summary of PE
- Summary of results
- Diagnoses
- Differential, if applicable
- Prognosis, if applicable
T/F: The assessment is typically written in complete sentences. - ANSWERSTrue
Does the assessment always begin with the age and sex of the patient? -
ANSWERSYes
What is the structure of a "simple statement" assessment? - ANSWERS- Age and sex
of the patient
- Summary of PMHx
- Diagnoses
Name four items, besides the diagnosis, that are typically included in a comprehensive
summary assessment. - ANSWERS- Age and sex of the patient
- Summary of PMHx
- Summary of HPI
- Summary of PE
Results Summary - ANSWERSALL new orders and results are included in the objective
section of the current chart, therefore ONLY results that are both new AND relevant to
the diagnoses will be summarized in the assessment.
Only include results that are... - ANSWERS...directly related to the patient's diagnosis or
differential.
Ask your physicians which results... - ANSWERS... are pertinent for the visit.
Training- Course 5: The S.O.A.P. Note -
Assessment and Plan(100% Correct)
Diagnosis - ANSWERSWhat the physician has determined to be the most likely cause
of the patient's symptoms
Assessment - ANSWERSA list of the patient's current diagnoses
Plan - ANSWERSThe currently laid out course of action to address the patient's
condition
Prognosis - ANSWERSA forecast of the likely course of a disease or ailment
Follow-up - ANSWERSOn-going contact with healthcare providers in order to address a
health concern
Diagnosis + Summary of visit = - ANSWERSAssessment
Assessment always includes... - ANSWERSDiagnosis: and/or differentials
Assessment may also include: - ANSWERS- Brief summary of the HPI: Typically chief
complaint and onset only
- Brief summary of physical exam: Pertinent findings only
- Summary of lab/imaging results: If new since the last visit
- Prognosis: Or justification for further testing or medication
T/F: When reviewing a previous visit, the physician is more likely to review the HPI than
the assessment because the HPI is more comprehensive - ANSWERSFalse
T/F: A diagnosis or differential diagnoses will always be listed in the assessment -
ANSWERSTrue
What are 3 items besides the diagnosis that may be documented in the assessment? -
ANSWERSBrief summary of HPI, Summary of PE, Summary of lab/imaging results
Assessment Structures (3) - ANSWERS- Simple Statement
- Brief Summary
- Comprehensive
The assessment is typically written in complete sentences.
, Simple Statement (3) - ANSWERS- Age and sex of patient
- Past medical history only if relevant
- Diagnoses
Brief Summary (6) - ANSWERS- Age and sex of patient
- Past medical history, if relevant
- Physical exam findings, if relevant
- Results, if new and relevant
- Diagnoses
- Differential, if no definitive diagnosis is found
Comprehensive Summary (9) - ANSWERS- Age and sex of patient
- Summary of PMHx
- Summary of HPI, including CC, onset, and important elements
- Summary of PE
- Summary of results
- Diagnoses
- Differential, if applicable
- Prognosis, if applicable
T/F: The assessment is typically written in complete sentences. - ANSWERSTrue
Does the assessment always begin with the age and sex of the patient? -
ANSWERSYes
What is the structure of a "simple statement" assessment? - ANSWERS- Age and sex
of the patient
- Summary of PMHx
- Diagnoses
Name four items, besides the diagnosis, that are typically included in a comprehensive
summary assessment. - ANSWERS- Age and sex of the patient
- Summary of PMHx
- Summary of HPI
- Summary of PE
Results Summary - ANSWERSALL new orders and results are included in the objective
section of the current chart, therefore ONLY results that are both new AND relevant to
the diagnoses will be summarized in the assessment.
Only include results that are... - ANSWERS...directly related to the patient's diagnosis or
differential.
Ask your physicians which results... - ANSWERS... are pertinent for the visit.
