Scribe Program

What are the categories of SOAP notes what does every letter mean?

● Subjective: patient’s description of illness, history, symptoms. Includes Chief complaint (CC), OPQRST, HPI, and ROS (we will go over this later).

● Objective: vital signs, PE findings, lab or X-ray findings (documentation of procedures)

● Assessment: acute and chronic condition diagnosis, differential diagnoses,

preventative care diagnosis (may also include updating the problem list)

● Plan: next steps for addressing each diagnosis including additional testing,

treatment plan and patient instructions

DME

durable medical equipment

What things do you include when pre-charting?

• return visit

• recent assessment plans and hospitalizations

• healthcare maintenance to be completed at the visit

types of orders provider could get

• meds

• lab tests

• imaging studies

Coag studies

PT/INR (prothrombin time )

blood thinner

coumadin (warfarin)

BMP

basic metabolic panel

• checks body fluids and kidney

CMP

comprehensive MP

• anaylysis of liver

CBC w/diff

complete blood count with differential white blood cell analysis

• screens for anemia or leukemia

  • weakness, fatigue, fever

Hepatitis screen

checks for infection, exposure, or vacc to hep

iron panel

• checks iron deficiency, leukemia, types of anemia

Pancreatic enzymes

amylase,lipase, pancreatitis

Prenatals

Streptococcus group b (GBS), CT/GT, RPR

• sets to ensure baby will not be exposed to infection during delivery

Thyroid (TSH)

• thyroid-stimulating hormone

• tests for hypo or hyperthyroidism

Uric Acid

gout

vitamins

B12, D

UA/culture

UTI, kidney function DM

ANA

antinuclear disease

BNP

brain natriuretic peptide

• marker for heart failure

Hgb A1c

PreDM and DM, blood glucose control over 3 months

Quantiferon gold

mTB

PSA

Prostate specific antigen

RF

Rheumatoid Factor

• Autoimmune disease

Bilirubin

Liver disease, constipation

Glucose

Kidney disease, DM, hyperthyroid

Ketones

Diabetic acidosis

Specific gravity

Hydration

What goes in Subjective notes?

HPI—> OPQRST, chief complaint, ROS, PMHx, PSHx, FHxRx, allergies, SHx

what goes in objective notes?

Vital signs, physical exam findings, laboratory data, imaging results ..etc

what goes in assessment notes?

diagnosis, differential diagnoses

what goes into plan notes?

testing, imaging, prescriptions, patient edu, specialists, referrals

Transverse

half up hald down

frontal/coronal

front back

sagittal

left side right side

blood pressue

90/120

respiratory rate

12-20

pulse

60-100

temp

97.8-99.7

VSS

vital signs stable

NAD

no acute distress

LMP

last menstrual cycle

PERRL

Pupils equal, round, reactive to light

EOM

Extaocular movements intact

LAD

lymphadenopathy

RRR

regular rhythm and rate

NSR

normal sinus rhythm

CTAB

clear to auscultation bilaterally

ROM

range of motion

HTN

hypertension

DM

diabetes mellitus

CHF

Congestive heart failure

COPD

chronic obstructive pulmonary disease

WNL

within normal limits

LFT’s

liver function tests

DVT

deep vine thrombosis

URI

Upper respiratory infection

ENT

Ears, nose, and throat

AMAB

Assigned male at birth

AFAB

Assigned female at birth

PMH

past medical history

HPI

history of present illness

OPQRST

Onset, provocation, quality, region/radiation, severity, timing

FHx

family history

Social history

SHx

ROS

review of systems

Vitals list

temp, spo2, BP, RR, HR, weight

Physical exam findings

general, neck, Cardiovascular, lungs, abdomen, extremities, neuro (a&o x3)