SCRIBE CLASS 3: THE SOAP NOTE (SUBJECTIVE)
1. SOAP: subjective, objective, assessment, plan
2. subjective: Based on the patient's feeling (HPI, ROS)
3. objective: Factual information from provider (PE)
4. History of Present Illness (HPI): The story of the patient's chief complaint
5. Review of Systems (ROS): Head-to-toe checklist of patient's symptoms
6. intermittent: comes and goes
7. waxing and waning: always present but changing in intensity
8. modifying factor: something that makes a symptom better or worse
9. exacerbate: to make worse
10.chart: A SOAP note is a method of organizing clinical info in a patient's .
11.workflow of the clinic: A SOAP note closely follows the that each portion is
documented consecutively as info is obtained from the pt.
12.SOAP- Subjective: information from the patient
13.Subjective includes:: Chief complaint, HPI, ROS
14.Objective (SOAP): information from the provider
15.Objective includes: vital signs, PE, orders/results
16.Assessment (SOAP): the pt's diagnoses
17.Assessment includes: a short description of progress since last visit
18.Plan (SOAP): treatment and follow-up for each diagnosis
19. T/F: The structure of the SOAP note closely follows the clinic
flow: T
20.T/F: You will usually document the assessment before documenting
the HPI: F
21. What are two components of the subjective
assessment?: HPI ROS
22.Which portion of the SOAP note contains results of orders?: --Assessment?
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, SCRIBE CLASS 3: THE SOAP NOTE (SUBJECTIVE)
23. 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?: Plan
24.subjective: info is the first item the physician discusses with the pt upon
entering the room
-it is the 1st section the scribe documents in the chart
25.Subjective includes: Chief complaint, HPI, ROS
26.CC: = main reason for the visit
27.HPI: = the story of the CC
28.ROS: = a checklist of symptoms from all body systems
29.subjective: In which portion of the chart: patient says "I have been vomiting on and
off for the past 3 days."
30.objective: Doctor says, "There is tenderness in the right upper quadrant."
31.objective: Doctor says: "the blood chemistry shows elevated LFTs."
2/9
, SCRIBE CLASS 3: THE SOAP NOTE (SUBJECTIVE)
32.subjective: pt says: "my abdominal pain feels dull and cramping."
33. what are 3 items that are included in the subjective evaluation?:
1) CC
2) HPI
3) ROS
34.always/every: include a CC.
level of billing requires a CC in order to be reimbursed for the service
provided.
35.Non-reimbursable CC: 1) check-up
2) follow-up
3) lab results
4) medication refill
36.Reimbursable CC: 1) 3 months diabetes management visit
2) HTN management evaluation
3) Discuss treatment options for elevated TSH
4) Evaluation of medication management for HTN
37.Why is it important to include CC on every chart?: reimbursement
38.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: ---
39.HPI: - story of symptoms/events that led to the clinic visit
-belongs at the beginning of the chart following CC
-summarized reason for visit
3/9
1. SOAP: subjective, objective, assessment, plan
2. subjective: Based on the patient's feeling (HPI, ROS)
3. objective: Factual information from provider (PE)
4. History of Present Illness (HPI): The story of the patient's chief complaint
5. Review of Systems (ROS): Head-to-toe checklist of patient's symptoms
6. intermittent: comes and goes
7. waxing and waning: always present but changing in intensity
8. modifying factor: something that makes a symptom better or worse
9. exacerbate: to make worse
10.chart: A SOAP note is a method of organizing clinical info in a patient's .
11.workflow of the clinic: A SOAP note closely follows the that each portion is
documented consecutively as info is obtained from the pt.
12.SOAP- Subjective: information from the patient
13.Subjective includes:: Chief complaint, HPI, ROS
14.Objective (SOAP): information from the provider
15.Objective includes: vital signs, PE, orders/results
16.Assessment (SOAP): the pt's diagnoses
17.Assessment includes: a short description of progress since last visit
18.Plan (SOAP): treatment and follow-up for each diagnosis
19. T/F: The structure of the SOAP note closely follows the clinic
flow: T
20.T/F: You will usually document the assessment before documenting
the HPI: F
21. What are two components of the subjective
assessment?: HPI ROS
22.Which portion of the SOAP note contains results of orders?: --Assessment?
1/9
, SCRIBE CLASS 3: THE SOAP NOTE (SUBJECTIVE)
23. 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?: Plan
24.subjective: info is the first item the physician discusses with the pt upon
entering the room
-it is the 1st section the scribe documents in the chart
25.Subjective includes: Chief complaint, HPI, ROS
26.CC: = main reason for the visit
27.HPI: = the story of the CC
28.ROS: = a checklist of symptoms from all body systems
29.subjective: In which portion of the chart: patient says "I have been vomiting on and
off for the past 3 days."
30.objective: Doctor says, "There is tenderness in the right upper quadrant."
31.objective: Doctor says: "the blood chemistry shows elevated LFTs."
2/9
, SCRIBE CLASS 3: THE SOAP NOTE (SUBJECTIVE)
32.subjective: pt says: "my abdominal pain feels dull and cramping."
33. what are 3 items that are included in the subjective evaluation?:
1) CC
2) HPI
3) ROS
34.always/every: include a CC.
level of billing requires a CC in order to be reimbursed for the service
provided.
35.Non-reimbursable CC: 1) check-up
2) follow-up
3) lab results
4) medication refill
36.Reimbursable CC: 1) 3 months diabetes management visit
2) HTN management evaluation
3) Discuss treatment options for elevated TSH
4) Evaluation of medication management for HTN
37.Why is it important to include CC on every chart?: reimbursement
38.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: ---
39.HPI: - story of symptoms/events that led to the clinic visit
-belongs at the beginning of the chart following CC
-summarized reason for visit
3/9
