SOAP

Ans: Subjective, Objective, Assessment, Plan

CHEDDAR

Ans: Chief complaint, Hx, Exam, Details of problem/complaint, Drugs &

dosages, Assessment, Return visit

Subjective

Ans: Pt complaint

Objective

Ans: Provider observation

Assessment

Ans: Medical Dx

Plan

Ans: Treatment

You are performing an audit of e/m services for a FP office. In the encounter you

read the physician ordered and reviewed a differential WBC. What elements

would you expect to see in the medical r...