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Class:MOA 145 - HEALTH CARE RECORDS MANAGEMENT
Subject:Medical Office Administration
University:Harper College
Term:Spring 2011
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SOAP; METHOD OR VARIATIONS S; this signifies subjective, subjective means from the patients point of view. This is the reason the patient is seeking care. It is the main problem necessitating care (also called chief complaint.).O: This refers to objective, or the physicians point of view, and what is found on physical examination, x-ray film, or laboratory work; the clinical evidence.A: This refers to assessment, or what the examiner thinks may be or is wrong with the patient according to the information gathered: the diagnosis.P: This refers to plan, or what the physician plans to do or advises the patient to do: laboratory tests, surgery, medications, referral to another practitioner, treatment, management and so forth.
Nonurgent care involves routine care that could have taken place in a physicians office during office hours. Chart note, emergency department visit
Urgent care involves care necessitating basic emergency services. Problems include lacerations, acute flu symptoms, and mild shortness of breath, broken bones, threatened abortion, and rectal bleeding. Admission to the hospital is possible.
Emergency care involves care requiring immediate attention of the physician. Problems include chest pain, stroke, and acute trauma, acute shortness of sitating cardiopulmonary
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also called chart notes or progress notes Medical record notes (also called chart notes or progress notes) are the formal or informal notes taken by the physician when he or she meets with or examines a patient in the office, clinic, acute care center, or emergency department. (Chapter 11) Introduction
permanent medical record; These notes are a part of the patients permanent medical record; medical records are vital in patient care although medical records are used mainly to assist the physician with care of the patient, they can be reviewed by attorneys, other physicians, insurance companies, or the court. It is essential that they be neat, accurate, and complete (Chapter 11) Introduction
Accurate means Accurate means that they are transcribed as dictated, and complete requires that they be dated and signed or initialed by the dictator. It is hard to insist that the physician sign or initial the records, but making it easier to do so: for example, by typing a line at the end of each chart entry for the signature or initials. (Chapter 11) Introduction
Persons dictating and those transcribing or editing records must follow established guidline Identify the patient by name and health record number when applicable on every page in the records or computerized record screen, every form, and every computerized printout. Make entries as soon as possible after an event or observation is made.(Entries are never made in advance.)Include a complete date and time on every entry.Use blank ink for written entries. You must ensure that these are legible.Use specific language; avoid vague or generalized language.Record objective facts, not what is presumedDocument what can be seen, heard, touched, and/or smelled.Describe signs or symptomsUse quotation marks when quoting the patient.Document the patients response to care.Use only abbreviation approved by the organization.
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generally found in these records and help you set it up in a logical manner 1.The records must be complete and legible.2.Each patient encounter should include the following documentation:DateReason for the encounterHistory, physical examination, prior diagnostic test resultsDiagnosis (assessment, impression)Plan for careName of the observer3.Rationale for ordering diagnosis or other services should be documented or inferred.4.Health risk factors should be identified.5.Progress, response to treatment, changes in treatment, and revision of diagnosis should be documented.
chief complaint (CC); The CC describes the symptom, problem, or condition that is the reason for the encounter and must be clearly describes in the record
the history of present illness (HPI); The HPI is the chronological description of the development of the patients present illness from the first sign and or/ symptom or from the previous encounter to the present.
past, family history, and / or social history (PFSH); The PFSH is a review of the patients past illnesses, operations, injuries and treatment; a review of medical events in the patients family, including diseases that may be hereditary; and a review of past and current activities in which the patient was or is engages.
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review of systems (ROS). A problem-pertinent ROS is an inquiry about the system directly related to the problems identified in the HPI. The patients positive responses identified in the HPI
BASIC FOUR the H & P, operative report, discharge summary, and consultation report. Furthermore, the H&P is the document that takes priority in transcription because it must be on the patients chart/record before certain other procedures can be carried out.
The SOAP format is a miniature H & P with the S ( subjective) portion taking the place of the history; the
the O (objective portion taking the place of the physical examination (PX OR PE);
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the A ( assessment) portion taking the place of the diagnosis portion of the examination;
the P ( Plan) portion taking the place of the outlined future treatment
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 SOAP; METHOD OR VARIATIONSS; this signifies subjective, subjective means from the patients point of view. This is the reason the patient is seeking care. It is the main problem necessitating care (also called chief complaint.).O: This refers to objective, or the physicians point of view, and what is found on physical examination, x-ray film, or laboratory work; the clinical evidence.A: This refers to assessment, or what the examiner thinks may be or is wrong with the patient according to the information gathered: the diagnosis.P: This refers to plan, or what the physician plans to do or advises the patient to do: laboratory tests, surgery, medications, referral to another practitioner, treatment, management and so forth.
 Nonurgent careinvolves routine care that could have taken place in a physicians office during office hours. Chart note, emergency department visit
 Urgent care involves care necessitating basic emergency services. Problems include lacerations, acute flu symptoms, and mild shortness of breath, broken bones, threatened abortion, and rectal bleeding. Admission to the hospital is possible.
 Emergency care

involves care requiring immediate attention of the physician. Problems include chest pain, stroke, and acute trauma, acute shortness of sitating cardiopulmonary
 also called chart notes or progress notes
Medical record notes (also called chart notes or progress notes) are the formal or informal notes taken by the physician when he or she meets with or examines a patient in the office, clinic, acute care center, or emergency department.
(Chapter 11) Introduction
 permanent medical record;
These notes are a part of the patients permanent medical record; medical records are vital in patient care although medical records are used mainly to assist the physician with care of the patient, they can be reviewed by attorneys, other physicians, insurance companies, or the court. It is essential that they be neat, accurate, and complete (Chapter 11) Introduction
 Accurate meansAccurate means that they are transcribed as dictated, and complete requires that they be dated and signed or initialed by the dictator. It is hard to insist that the physician sign or initial the records, but making it easier to do so: for example, by typing a line at the end of each chart entry for the signature or initials. (Chapter 11) Introduction
 Persons dictating and those transcribing or editing records must follow established guidlineIdentify the patient by name and health record number when applicable on every page in the records or computerized record screen, every form, and every computerized printout. Make entries as soon as possible after an event or observation is made.(Entries are never made in advance.)Include a complete date and time on every entry.Use blank ink for written entries. You must ensure that these are legible.Use specific language; avoid vague or generalized language.Record objective facts, not what is presumedDocument what can be seen, heard, touched, and/or smelled.Describe signs or symptomsUse quotation marks when quoting the patient.Document the patients response to care.Use only abbreviation approved by the organization.
 generally found in these records and help you set it up in a logical manner1.The records must be complete and legible.2.Each patient encounter should include the following documentation:DateReason for the encounterHistory, physical examination, prior diagnostic test resultsDiagnosis (assessment, impression)Plan for careName of the observer3.Rationale for ordering diagnosis or other services should be documented or inferred.4.Health risk factors should be identified.5.Progress, response to treatment, changes in treatment, and revision of diagnosis should be documented.
 chief complaint (CC); The CC describes the symptom, problem, or condition that is the reason for the encounter and must be clearly describes in the record
 the history of present illness (HPI); The HPI is the chronological description of the development of the patients present illness from the first sign and or/ symptom or from the previous encounter to the present.
 past, family history, and / or social history (PFSH); The PFSH is a review of the patients past illnesses, operations, injuries and treatment; a review of medical events in the patients family, including diseases that may be hereditary; and a review of past and current activities in which the patient was or is engages.
 review of systems (ROS). A problem-pertinent ROS is an inquiry about the system directly related to the problems identified in the HPI. The patients positive responses identified in the HPI
 BASIC FOUR
the H & P, operative report, discharge summary, and consultation report. Furthermore, the H&P is the document that takes priority in transcription because it must be on the patients chart/record before certain other procedures can be carried out.
 The SOAP format is a miniature H & P with the S ( subjective)


portion taking the place of the history; the
 the O (objective

portion taking the place of the physical examination (PX OR PE);
 the A ( assessment)

portion taking the place of the diagnosis portion of the examination;
 the P ( Plan)

portion taking the place of the outlined future treatment
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