ScribeAmerica Outpatient Course 3
SOAP - subjective, objective, assessment, plan
subjective
-info from?
-what is it comprised of - information coming from the patient based on the patient's
feeling
composed of :
CC - reason for their visit
HPI - The story of the patient's chief complaint
ROS -Head to toe checklist of patient's symptoms
Objective
-what is it
-what does it include? this means what staff member can provide it? - Factual
information from provider (PE, observation of physican, vital signs, orders, results of
orders)
can come from both provider and clinic staff (vitals)
Assessment (2) - The patient's diagnoses
A short description of progress from their last visit
Plan - Follow up and treatment plan for each diagnoses
Soap structure -
past history is important because - They can be risk factors
important terminology -
Carotid Endarterectomy (CEA) - surgical procedure to remove blockage from the ICA
with goal of reducing risk of stroke
SOAP note quizes -
S is for subjective (in depth)
-how does it differ in pediatrics
-in the elderly ?
, ScribeAmerica Outpatient Course 3
-it is the _____ that a physician discusses
it is the _____ thing documented - in pediatrics, the historian will the parent
son/daughter may be historian in the elderly
-it is the first item the physician discusses with the patient when entering the room
-It is the first thing that is documented
Subjective content in depth
-three components of the subjective - CC may not be the only thing that is dealt with
during the session. There could be multiple CCS
cc - main reason for the visit
HPI explains the story of the chief complaints
ROS is a checklist of symptoms from all body symptoms from head to toe
which of the following have different names when describe subjectively or objectively ? -
Pain/Discomfort
(difference between subjective pain and objective tenderness that comes from a doctors
observation after palpating)
objective - when i push here it worsens pain for the patient
intermittent - comes and goes
waxing and waning - always present but changing in intensity
modifying factor - something that makes a symptom better or worse
alleviating - make symptom better
exacerbate - to make worse (make symptoms worse)
is it subjective or objective -
S.O.A.P note- definition - A SOAP note is a method of organizing clinical information in
a patient's chart. It closely follows the workflow of the clinic so that each portion of the
SOAP note is documented consecutively as information is obtained from the patient
SOAP note closely follows the - work flow of the clinic so that each portion of the SOAP
note is documented consecutively as information is obtained from the patient
SOAP - subjective, objective, assessment, plan
subjective
-info from?
-what is it comprised of - information coming from the patient based on the patient's
feeling
composed of :
CC - reason for their visit
HPI - The story of the patient's chief complaint
ROS -Head to toe checklist of patient's symptoms
Objective
-what is it
-what does it include? this means what staff member can provide it? - Factual
information from provider (PE, observation of physican, vital signs, orders, results of
orders)
can come from both provider and clinic staff (vitals)
Assessment (2) - The patient's diagnoses
A short description of progress from their last visit
Plan - Follow up and treatment plan for each diagnoses
Soap structure -
past history is important because - They can be risk factors
important terminology -
Carotid Endarterectomy (CEA) - surgical procedure to remove blockage from the ICA
with goal of reducing risk of stroke
SOAP note quizes -
S is for subjective (in depth)
-how does it differ in pediatrics
-in the elderly ?
, ScribeAmerica Outpatient Course 3
-it is the _____ that a physician discusses
it is the _____ thing documented - in pediatrics, the historian will the parent
son/daughter may be historian in the elderly
-it is the first item the physician discusses with the patient when entering the room
-It is the first thing that is documented
Subjective content in depth
-three components of the subjective - CC may not be the only thing that is dealt with
during the session. There could be multiple CCS
cc - main reason for the visit
HPI explains the story of the chief complaints
ROS is a checklist of symptoms from all body symptoms from head to toe
which of the following have different names when describe subjectively or objectively ? -
Pain/Discomfort
(difference between subjective pain and objective tenderness that comes from a doctors
observation after palpating)
objective - when i push here it worsens pain for the patient
intermittent - comes and goes
waxing and waning - always present but changing in intensity
modifying factor - something that makes a symptom better or worse
alleviating - make symptom better
exacerbate - to make worse (make symptoms worse)
is it subjective or objective -
S.O.A.P note- definition - A SOAP note is a method of organizing clinical information in
a patient's chart. It closely follows the workflow of the clinic so that each portion of the
SOAP note is documented consecutively as information is obtained from the patient
SOAP note closely follows the - work flow of the clinic so that each portion of the SOAP
note is documented consecutively as information is obtained from the patient
