COMLEX PE CH 7

1. What are the general guidelines to writing a SOAP note?

a. SOAP note must be written in English and legible
b. Notes must be written within the boxes
c. Each note must begin with the date and time of the encounter
d. Avoid using abbreviations
2. How do you document and structure the Subjective section?
a. Always begins with the chief complaint
b. CODIERS portion of the history in paragraph form
c. SMASH FM information written in outline form
3. How do you document and structure the Objective section?
a. Vital signs
b. Physical examination in outline format with headings for each system
i. Must always include assessment of heart and lungs
4. How do you document and structure the Assessment section?
a. Differential diagnoses numbered in order of likelihood
i. Include a minimum of 4 possible diagnoses
ii. Permissible to write “Rule out” or “Doubt” in front of least likely diagnoses
b. Differentials must be supported by the history and physical exam
c. Secondary diagnoses not related to the chief complaint should also be noted
5. How do you document and structure the Plan section?
a. Treatment plan: MOTHRR
b. Document drug name, dose, and frequency
c. Perform OMM with an associated somatic dysfunction
i. Note areas of treatment and techniques used
d. Order specific tests such as BUN, creatinine, etc
6. What is the definition of False Documentation?
a. Documenting any history that was not actually asked or document portions of the
examination or osteopathic manipulation that were not truly performed
7. How long is the SOAP note documentation?
a. 9 minutes
8. When do you get a warning before the SOAP note documentation session is over?
a. 2 minutes nearing the 9 minute mark