Interviewing and Documentation

Question 1

What information goes into the subjective portion of a SOAP note?

Answer 1

chief complaint
allergies
history of present illness
past medical history
family history
social history
review of symptoms

Question 2

what information goes into the objective portion of a SOAP note?

Answer 2

exam
labs/diagnostic tests

Question 3

what is a MTR?

Answer 3

medication therapy review: reviews patient-specific inforamation

Question 4

what is a PMR?

Answer 4

personal medication record

Question 5

what is a MAP?

Answer 5

medication-related action plan

Question 6

what are the 7 attributes of a symptom? (LQQ/STORA)

Answer 6

location
quality
quantity/severity
timing
onset
remitting or exacerbating factors
associated manifestations