Scribe.ology General Concepts

What does SOAP stand for?

Subjective

Objective

Assessment

Plan

Where is the SOAP note recorded?

Electronically recorded in a patient’s EMR/EHR (Electronic Medical Record/Electronic Health Record)

What does the term “provider” include?

Physicians

Nurse Practitioners

PAs

What does Subjective component of the EMR/EHR include?

Any info that comes from the patient or their family that includes when the problem first started, all the symptoms that the patient has and anything else that is pertinent to why the patient is seeking evaluation

What is considered to be the subjective component of the EMR/EHR?

Patient’s chief complaint

History of present illness (HPI)

Past medical history

Medications

Allergies

Social history

Family history

What does the Objective component of the EMR/EHR include?

Any information that comes from the provider (measured, seen, heard, touched, felt, or smelled)

What is the major part of the objective section of the EMR/EHR?

Medical Decision Making (MDM)

What is considered to be the objective components?

Vital signs

Physical examination

Laboratory data

What does the Assessment component of the EMR/EHR include?

The diagnosis of the patient’s condition (the result of the provider’s medical evaluation)

What is considered to be the assessment components?

Diagnosis

Differential diagnosis

Assessment of progress

What does the Plan component of the EMR/EHR include?

What the provider plans to do with the patient moving forward, indicating what the patient needs to complete for long term care and what future planning is necessary by the provider

What is considered to be the plan components?

Treatment plan

Education

Follow-up

Prognosis

When a patient has multiple complaints, which one is the chief complaint?

The most pressing need

What are some examples of a chief complaint?

Headache

Cough

Back pain

Chest pain

From what perspective is an HPI told?

Patient’s perspective

What is the purpose of an HPI?

To give a detailed but concise explanation of why the patient is needing medical treatment, along with summarizing any pertinent medical history

What are the elements of an HPI?

Location/Radiation

Context

Duration

Onset

Character

Related symptoms

Alleviating/Aggravating factors

Severity

What abbreviation helps with remembering the elements of an HPI?

COLD CARS

What is the general format of and HPI?

“Patient’s name” presents for evaluation of “Chief Complaint and Location”, onset… while/during “Onset/Context”. He/She describes the symptom(s) as “Quality and Severity”. He/She also reports “Associated signs and symptoms and/or denies pertinent negatives”. “Modifying factors” affects “how?” the symptom(s).

How does the history help?

It aids the physician in their diagnosis and provide a view into the patient’s general state of being

What are the different categories that histories are split into?

Prior medical history (PMHx)

Prior surgical history (PSHx)

Social history (SHx/SocHx)

Family history (FHx)

How are PMHx and PSHx obtained?

Hospital records, charts and summaries the patient will bring in, or obtained directly from the patient

What is the “however” of obtaining PMHx and PSHx?

It is difficult to verify the information

How is SHx and FHx obtained?

Direct interviewing of the patient

What can the ROS be thought of?

A “catch all” for everything going on with the patient at the time of examination

How are the answers of ROS recorded?

Either positive or negative in an itemized list

What does the ROS include?

Symptoms discussed in the HPI

Every symptom that the patient is experiencing at the time of examiation

How is the ROS organized?

By functional organ system

In the ROS, what does “positive” mean?

Symptom is present

In the ROS, what does “negative” mean?

Symptom is not present

What does the phrase “all other systems negative” indicate?

Anything not specifically mentioned in the ROS are assumed to be negative

When is a PEx performed?

During or after interviewing the patient for the first time

Describe the information found in the PEx

Varys greatly depending on the doctor performing it performing it, the patient’s chief complaint, and the ability of the patient to cooperate with the exam

Organized using itemized body systems

Contains objective information

What are the parts of MDM?

Consists of Differential Diagnoses (DDx), along with the explanation for why each of the diagnoses were or were not part of the final diagnosis

What are the 3 categories that disposition can fall into?

Discharge

Admit

Transfer

What does the scribe portion of the scribe attestation look like?

I certify that I, “name”, acting as scribe have transcribed this note for “Provider Name MD/DO”

What are some medications for hypertension?

Bystolic (Nebivolol)

Catapress (Clonidine)

Coreg (Carvedilol)

Diovan (Valsartan)

Lasix (Furosimide)

Lopressor (Metoprolol)

Microzide (Hydrochorothiazide (HCTZ))

Norvasc (Amlodipine)

Tenormin (Atenolol)

What are some medications for hypertension and chronic kidney disease?

Cozaar (Losartan)

Zestril (Losonopril)

What are some blood thinners?

Asprin

Coumadin (Warfarin)

Heparin

Lovenox (Enoxaparin sodium)

Plavix (Clopidogrel)

Xarelto (Rivaroxaban)

What are some cholesterol medications?

Zocor (Simvastatin)

Lipitor (Atorvastatin)

Mevacor (Lovastatin)

Crestor (Resuvastatin)

Welchol (Colesvelam)

Zetia (Ezetimibe)

What are some medications for angina?

Cardizem (Diltiazem)

Nitrostat (Nitroglycerin)

Nitro-Bid (Nitropaste)

What medication is used for congestive heart failure?

Digoxin (Lanoxin)

What are some ACLS?

Adenosine

Amiodarone

Atropine

Cardizem (Diliazem) injection

Dopamine

Epinephrine

Norepinephrine

Sodium bicarbonate

Vasopressin

What are some treatments for chronic lung conditions?

Ipratropim bromide (Atrovent)

Proventil, Proair, Ventolin (Albuterol)

Terbulin (Tertbutaline)

Theolair (Theophylline)

Xopenex (Levalbuterol)

What are some treatments for a stroke?

Streptokinase

tPA

What is a treatment for hypoglycemia?

Aldoril D50 (Dextrose)

What are some treatments for hyperglycemia?

Huma-log (Insulin)

Januvia (Sitagliptin)

Glucophage (Metformin)

Lantus (Insulin glargine)

What are some treatments for heartburn/gastroesophageal reflux disease?

Nexium (Esomeprazole)

Prilosec (Omeprazole)

Protonix (Pantoprazole)

Zantac (Ranitidine)

What treatments are there for vomiting?

Bentyl (Dicyclomine)

Compazine (Prochlorperazine)

Phenergan (Promethazine)

Reglan (Metoclorpramide)

Skelaxin (Metaxalone)

Zofran (Ondansetron)

What is an enlarged prostate treatment?

Flomax (Tamsulosin)

What are some treatments for sexual dysfunction?

Cialis (Tadalafil)

Levitra (Vardenafil)

Viagra (Sildenafil)

What are some treatments for seizure activity?

Depakote (Valproic acid)

Dilantin (Phenytoin)

Lamotrigine (Lamictal)

Tegretol (Carbamazepine)

What are some treatments for anxiety?

Ativan (Lorazepam)

Diazepam (Valium)

Effexor (Venlafaxine)

Klonopin (Clonazepam)

Nembutal (Pentobarbital)

Versed (Midazolam)

Xanax (Alprazolam)

What are some treatments for ADHD (stimulants)?

Adderall (Dextroamphetamine)

Concerta/Ritalin (Methylphenidate)

Vyvanse (Lisdexamfetamine)

What are some treatments for bipolar disorder/schizophrenia?

Seroquel (Quetiapine)

Risperdal (Risperidone)

What is a treatment for combative behavior?

Haldol (Haloperidol)

What are some treatments for depression?

Celexa (Citalopram)

Cymbalta (Duloxetine)

Lexapro (Escitalopram)

Paxil (Paroxetine)

Prozac (Fluoxetine)

Wellbutrin (Bupropion)

Zoloft (Sertraline)

What are some treatments for drug withdrawal/abuse?

Narcan (Naloxone)

Romazicon (Flumazenil)

What are some sleep medications?

Ambien (Zolpidem)

Lunesta (Eszopiclone)

Silenor (Doxepin)

Phenobarbital

What is a treatment for a foreign body in the eye?

Fluorescein

What is a treatment for dry eyes?

Restasis (Cyclosporine ophthalmic emulsion)

What are some treatments for glaucoma?

Alphagan (Brimonidine tartrate)

Combigan (Brimonidine/timolol)

Iopidine (Apraclondine)

What are some acne medications?

Aldactone (Spironolactone)

Benzaclin (Benzoyl peroxide/Clindamycin)

Claravis (Accutane/Isotretinion)

Clindagel (Clindamycin)

Differin (Adapalene)

Retin-A (Tretinoin)

Tazorac (Tazarotene)

What are some treatments for skin infestations?

Elimite (Permethrin)

Soolantra (Ivermectin)

What are some birth control medications/treatments?

Alesse

Depo-Provera injection

Estrostep

Levlen

Levora

Loestrin

Mircette

Nordette

Ogesterel

Ortho Evra Patch

Ortho-Novum

Yasmin

Yaz

IUD

What are some anethetics?

Diprovan (Propofol)

Etomidate (Amidate)

Ketamine

Lidoderm (Lidocaine)

What are some addictive narcotic pain control medications?

Codeine

Demerol (Meperidine)

Dilaudid (Hydromorphone)

Hydrocodone

Lortab/Norco/Vicodin (Hydrocondone/Acetaminophen)

Morphine

Percocet (Oxycodone/Acetaminophen)

Tylenol #3 (Co-codamol)

What is a neurological pain control medication?

Nerontin (Gabapentin)

What is a medication for headaches/migranes?

Imitrex (Sumatriptan)

What are some NSAIDs?

Advil (Ibuprofen)

Aleve (Naproxen)

Mobic (Meloxicam)

Toradol (Ketorolac)

What are some medications for oral steroidal symptom control?

Cortisone

Decadron (Dexamethasone)

Deltasone (Prednisone)

Medrol Dose Pack (Methylprednisolone)

Omnipred (Prednisolone)

What are some medications for topical steroidal symptom control?

Clobestasol propionate

Desonate (Desoinide)

Hydrocortisone

Kenalog (Triamcinolone)

What are some antibiotics?

Avelox (Moxifloxacin)

Bactrim (Sulfamethoxazole/trimethoprim)

Bactroban (Mupirocin)

Bicilin

Cefazolin

Cipro (Ciprofloxacin)

Clindamycin

Flagyl (Metronidazole)

Flurorquinolone

Fortaz (Ceftazidime)

Keflex (Cephalexin)

Levaquin (Levofloxacin)

Mefoxin (Cefoxitin)

Moxatag (Amoxicillin)

Neomycin

Rocephin (Ceftriaxone)

Teflaro (Ceftaroline)

Unasyn (Ampicillin/sulbactam)

Vancocin (Vancomycin)

Zosyn (Piperacillin and Tozobactam)

Z-pack (Azithromycin)

What are some over the counter medications for fever/pain relief?

Ibuprofen

Motrin

Tylenol

What are some over the counter antihistamine medications?

Allegra (Fexofenadine)

Benadryl (Diphenhydramine)

Claritin (Loratadine)

Zyrtec (Cetirzine)

What are some over the counter common cold/cough medications?

Airborne

DayQuil

NyQuil

Robitussin (Dextromethorphan)

What are some over the counter nasal congestion medications?

Flonase (Fluticasone propionate)

Sudafed (pseudoepherine)

What is a over the counter sore throat medications?

Cough drops (benocaine)

What are some over the counter bloating/GI discomfort medications?

Calcium carbonate

Gas-X (Simethicone)

Pepcid

What are some over the counter antinausea medications?

Dramamine (Dimenhydrinate)

Peptobismal (Bismuth subsalicylate)

What is a over the counter antidiarrhea medications?

Imodium (Loperamide)

What are some over the counter constipation aids medications?

Benefiber

Metamucil

Milk of Magnesia

Miralax

Colacel

What is an over the counter warts medication?

Salicylic acid (topical)

What is an over the counter sleep medication?

Melatonin