EMR SOAP Note Final Exam With Complete Questions And Detailed Correct Answers/22024.

S.O.A.P note - correct answer Subjective Objective Assessment Plan Subjective - correct answer -This section is reported by the patient. -It is important to specify who is providing the information (patient, guardian, a nurse, etc.) -Pediatric patients must always have an adult present to speak on their behalf. -You must also consider if the source of information is reliable. If the person giving the history seems unsure of important details, they should be recorded as a poor historian. Subjective Chief Complaint - correct answer -A quick description of why the patient is being seen. -This can be a few words (i.e. chest pain) or a sentence (i.e. "Ben is a 45 yo male who presents with chest pain") Subjective History of Present Illness (HPI) - correct answer -Provides a clear thought process of the clinician. -It adds detail about the patient's visit and gives background including associated risk factors and pertinent personal and family history. -The HPI should be exceedingly clear and concise while still being thorough. Subjective History of Present Illness (HPI) - Intro - correct answer -The first sentence of an HPI should allow the reader to understand who the patient is and why they are being seen. -Start with name, age, and gender of the patient as well as their chief complaint for a solid foundation. -"Bruce is a 21 yo male presenting with abdominal pain." -Then add any relevant details such as past medical conditions, family history, or risk factors. -"Bruce i a 21 yo male with a history of hypertension, presenting in the office with abdominal pain. Subjective HPI body - correct answer -The next few sentences should explain more about the current condition. -A good tool to use in order to add extra details is the acronym OPPQRST. -Onset: this section described how the symptoms began, what the patient was doing at the time, and if it was sudden or gradual. -Provocative: what made it worse? -Palliative: what made it better? -Quality: description of the symptoms (dull, sharp, achy, cramping) -Radiation: location of the symptom, whether it's diffuse or localized, and if the symptom travels anywhere else in the body. -Severity: usually quantifies the pain on a scale of 1-10, with 10 being the worst pain the patient has ever experienced. -Timing: how frequently does the symptom occur? -Timing of the ___ section should start from the beginning and work towards the present. -Consider if there were any hospitalizations, surgeries, diagnostic tests and results. -Following the history is the pertinent positives and negatives. -The provider may ask questions regarding associated symptoms with the condition. -In the example about Bruce's abdominal pain, the provider may also ask about fever, nausea, or vomiting. Subjective History of Present Illness (HPI) - Ending - correct answer -The natural flow of the history transitions with the provider's thought process. -The direction of the note will address other systems as they attempt to formulate a differential diagnosis. -In the example about Bruce's abdominal pain, the provider may begin to address cardiovascular symptoms as well. -It is to group information together as best as possible as each series of questions are meant to eliminate certain possibilities the patient may be diagnosed with. Subjective History of Present Illness (HPI) Extra details - correct answer -Use proper medical terminology as much as possible. -Keep in mind working environments may be chaotic and recording all these details may be difficult as certain details may not be addressed or may be answered out of order from what you are intending to write. -This may require you to readdress this information with the patient or the provider. -Each provider also has their own style so you may find yourself adapting to their preferences. -These preferences may include specific details to records, usage of certain pronouns (like using "the patient" instead of "he/she"), and key phrases, terms, or abbreviations. -Fragments are ok if done properly. For example, "No recent hospitalizations or surgeries. No previous medical history." HPI Verbiage - Admits - correct answer -When asked a question by the provider, patient responds with affirmation (i.e. patient admits to coughing) HPI Verbiage - Denies - correct answer -When asked a question by the provider, patient responds with a negative (i.e. patient denies any chest pain) HPI Verbiage - Describes - correct answer -Usually used when patient is describing pain or qualitative properties (i.e. she describes the pain as dull) HPI Verbiage - Endorses - correct answer -To support, when a patient answers a question with affirmation (i.e. patient endorses having a dry cough) HPI Verbiage - Gestures - correct answer -When a patient uses hand gestures to point out a body region (i.e. patient gestures towards pain in her left thigh region) HPI Verbiage - Reports - correct answer -Used when a patient makes a statement about their history, can be interchanged with "states" or "notes" (i.e. patient reports he has been experiencing chest pains) Subjective Review of Systems (ROS) - correct answer -This section covers all the systems of the body from general/constitutional to genitourinary. -The information provided in the HPI should be addressed in the ROS as well. -For example, if the