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Scribe America Outpatient Pre-Clinical Training- Course 5 The S.O.A.P. Note - Assessment and Plan Exam Questions and Answers $12.49   Add to cart

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Scribe America Outpatient Pre-Clinical Training- Course 5 The S.O.A.P. Note - Assessment and Plan Exam Questions and Answers

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Diagnosis - Answer-What the physician has determined to be the most likely cause of the patient's symptoms Assessment - Answer-A list of the patient's current diagnoses Plan - Answer-The currently laid out course of action to address the patient's condition Prognosis - Answer-A forecast of...

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  • September 11, 2024
  • 8
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Scribe America outpatient
  • Scribe America outpatient
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lectknancy
Scribe America Outpatient Pre-Clinical
Training- Course 5 The S.O.A.P. Note -
Assessment and Plan Exam Questions
and Answers
Diagnosis - Answer-What the physician has determined to be the most likely cause of
the patient's symptoms

Assessment - Answer-A list of the patient's current diagnoses

Plan - Answer-The currently laid out course of action to address the patient's condition

Prognosis - Answer-A forecast of the likely course of a disease or ailment

Follow-up - Answer-On-going contact with healthcare providers in order to address a
health concern

Diagnosis + Summary of visit = - Answer-Assessment

Assessment always includes... - Answer-Diagnosis: and/or differentials

Assessment may also include: - Answer-- Brief summary of the HPI: Typically chief
complaint and onset only
- Brief summary of physical exam: Pertinent findings only
- Summary of lab/imaging results: If new since the last visit
- Prognosis: Or justification for further testing or medication

T/F: When reviewing a previous visit, the physician is more likely to review the HPI than
the assessment because the HPI is more comprehensive - Answer-False

T/F: A diagnosis or differential diagnoses will always be listed in the assessment -
Answer-True

What are 3 items besides the diagnosis that may be documented in the assessment? -
Answer-Brief summary of HPI, Summary of PE, Summary of lab/imaging results

Assessment Structures (3) - Answer-- Simple Statement
- Brief Summary
- Comprehensive

The assessment is typically written in complete sentences.

, Simple Statement (3) - Answer-- Age and sex of patient
- Past medical history only if relevant
- Diagnoses

Brief Summary (6) - Answer-- Age and sex of patient
- Past medical history, if relevant
- Physical exam findings, if relevant
- Results, if new and relevant
- Diagnoses
- Differential, if no definitive diagnosis is found

Comprehensive Summary (9) - Answer-- Age and sex of patient
- Summary of PMHx
- Summary of HPI, including CC, onset, and important elements
- Summary of PE
- Summary of results
- Diagnoses
- Differential, if applicable
- Prognosis, if applicable

T/F: The assessment is typically written in complete sentences. - Answer-True

Does the assessment always begin with the age and sex of the patient? - Answer-Yes

What is the structure of a "simple statement" assessment? - Answer-- Age and sex of
the patient
- Summary of PMHx
- Diagnoses

Name four items, besides the diagnosis, that are typically included in a comprehensive
summary assessment. - Answer-- Age and sex of the patient
- Summary of PMHx
- Summary of HPI
- Summary of PE

Results Summary - Answer-ALL new orders and results are included in the objective
section of the current chart, therefore ONLY results that are both new AND relevant to
the diagnoses will be summarized in the assessment.

Only include results that are... - Answer-...directly related to the patient's diagnosis or
differential.

Ask your physicians which results... - Answer-... are pertinent for the visit.

Pertinent results include: (2) - Answer-- Positive results confirming a diagnosis
- Negative results that have ruled out a diagnosis

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