Outpatient 3: SOAP-subjective
Intermittent - ANSComes and goes
Waxing and waning - ANSAlways present but changing in intensity
Modifying factor - ANSSomething that makes a symptom better or worse
Exacerbate - ANSTo make worse
T/F : The structure of the SOAP note closely follows the clinic flow. - ANSTrue
T/F : You will usually document the assessment before documenting the HPI. - ANSFalse
What are two components of the subjective assessment? - ANSHPI and ROS
Which portion of the SOAP note contains the results of orders? - ANSObjective
The doctor says to the patient, "I'd like you to follow up with your GI doctor in the next two
weeks." In what section of the SOAP note does this belong? - ANSPlan
In which portion of the chart does each of the following statements belong - subjective or
objective?
1.) Patient says: "I have been vomiting on and off for the past 3 days."
2.) Doctor says: "There is tenderness in the right upper quadrant."
3.) Doctor says: "The blood chemistry shows elevated LFTs."
4.) Patient says: "My abdominal pain feels dull and cramping." - ANS1.) subjective 2.) objective
3.) objective 4.) subjective
What are three items that are included in the subjective evaluation? - ANSchief complaint, HPI,
ROS
Why is it important to include a chief complaint on every chart? - ANSIn order to be reimbursed
for the service provided
Fix the following chief complaints to make them billable:
1. Results of bloodwork (low hemoglobin)
2. HTN follow-up
3. Refill of lisinopril
4. Check-up - HLD - ANS1. discussed low hemoglobin treatment
2. HTN management evaluation
3. evaluation of medication management
Intermittent - ANSComes and goes
Waxing and waning - ANSAlways present but changing in intensity
Modifying factor - ANSSomething that makes a symptom better or worse
Exacerbate - ANSTo make worse
T/F : The structure of the SOAP note closely follows the clinic flow. - ANSTrue
T/F : You will usually document the assessment before documenting the HPI. - ANSFalse
What are two components of the subjective assessment? - ANSHPI and ROS
Which portion of the SOAP note contains the results of orders? - ANSObjective
The doctor says to the patient, "I'd like you to follow up with your GI doctor in the next two
weeks." In what section of the SOAP note does this belong? - ANSPlan
In which portion of the chart does each of the following statements belong - subjective or
objective?
1.) Patient says: "I have been vomiting on and off for the past 3 days."
2.) Doctor says: "There is tenderness in the right upper quadrant."
3.) Doctor says: "The blood chemistry shows elevated LFTs."
4.) Patient says: "My abdominal pain feels dull and cramping." - ANS1.) subjective 2.) objective
3.) objective 4.) subjective
What are three items that are included in the subjective evaluation? - ANSchief complaint, HPI,
ROS
Why is it important to include a chief complaint on every chart? - ANSIn order to be reimbursed
for the service provided
Fix the following chief complaints to make them billable:
1. Results of bloodwork (low hemoglobin)
2. HTN follow-up
3. Refill of lisinopril
4. Check-up - HLD - ANS1. discussed low hemoglobin treatment
2. HTN management evaluation
3. evaluation of medication management
