Brief Overview of Scribing a SOAP Note

Module Overview

The following information is reviewed…

What is a SOAP Note

Brief overview of the “Subjective” elements

Brief overview of the “Objective” elements

Brief overview of the “Assessment elements

Brief overview of the “Plan” elements

Subjective
What is a SOAP Note?

A SOAP Note is a method of organizing

clinical information in a patient’s chart. It
allows providers to record and share
information in a universal, systematic,
and easy to read format.

It closely follows the typically workflow of

the clinic/patient encounter so that each
portion of the SOAP Note is documented
sequentially as information is received
from the patient.
Subjective Information vs Objective Information

SUBJECTIVE INFORMATION
Personal opinions, perceptions,
assumptions, interpretations, beliefs, etc
from the patient’s point of view

OBJECTIVE INFORMATION
Observations, testing, results, treatment
plan, etc from the provider’s point of
view
Sections of a SOAP Note

SUBJECTIVE (S)
OBJECTIVE (O)
Chief Complaint (CC) A SOAP Note typically
History of Present Illness (HPI) Vitals (VS)
contains these categories
Review of Systems (ROS) Physician Statement
Examination findings
and subcategories
Past Medical History (PMH)
Past Surgical History (PSH)
Current Medications
The DeepScribe Web App
Allergies PLAN (P) (Falcon) follows this order
Family History (FH)
Social History (SH) Treatment Options and also include color
Procedures coordination.
Immunizations
Diagnostic Imaging S = CORAL/PINK/RED
ASSESSMENT (A) Additional Labs O = SHERBERT/ORANGE
Diagnoses Preventative Measures A = PERIWINKLE/BLUE-PURPLE
New Medications P = PINK-ISH LAVENDER
Follow-up
Subjective Information Includes

PAST MEDICAL,
HISTORY OF PRESENT REVIEW OF SYSTEMS
FAMILY, & SOCIAL
CHIEF COMPLAINT ILLNESS (HPI) (ROS)
HISTORY
(CC) The story of the Chief A checklist of
Summary of medical
Reason for the visit Complaint symptoms from all
history and current
body systems
lifestyle

Subjective information is the first part of the patient encounter.

The subjective information is given to the physician by the person giving the history –
typically the patient is the historian.
When writing your SOAP Note, it is important to state who the information is coming from.
Ex: “The patient complaints of a sore throat that began 2 days ago.”
For pediatric patients, the parent/caregiver may be the historian.
Ex: “The patient’s mother states the patient has had 2 episodes of emesis today.”
History of Present Illness (HPI): Importance

The HPI is one of the most important sections of the SOAP Note because the entire
provider workup is determined by the details discussed during the HPI.

The HPI should tell a detailed story, so that the person reading it knows exactly what the
patient was seen for during that visit.

Subjective Objective

CC: HPI: ROS: PE: PE / Test: Assessment: Plan:

Sore Throat Began 2 days + sore throat Bilateral Rapid Strep Strep Throat Rx for
ago. - fever tonsillar Test Amoxicillin.
“Burning”. exudate Recommend
- runny nose
Worse with salt gargles.
swallowing
OTC
Ibuprofen for
pain
8 Elements of the HPI

There are 8 elements of the HPI that you must be familiar with:

Element Description
Onset When did the symptoms begin? (e.g two weeks ago, 11/23/2022, last night at 9 pm)
Timing How frequent is/are the symptom(s)? (e.g constant, intermittent, occasional)
Location Where is/are the symptom(s) located? (RUQ, right upper arm, left lower leg, lower back)
Quality How the patient describes the symptoms (e.g burning, achy, dull, stabbing, sharp, etc)
Severity Strength of the symptom(s) (i.e how bad is the pain? scale of 1-10, mild/moderate/severe)
Modifying Things that make the symptoms better or worse (e.g moderate relief with Aleve, pain is better
Factors when sitting down, pain is worse with walking)
Associated Other symptoms that accompany the chief complaint (e.g if the chief complaint is cough,
Symptoms associated symptoms usually include rhinorrhea, sore throat, etc)
Context What was the patient doing when the symptom occurred? Other pertinent information.
Medical History

A patient’s “medical history” can fall into a few categories:

● Medications = includes current medications

● Allergies = includes allergies (medications, food, environmental)

● Medical History = includes chronic and resolved conditions

● Surgical History = includes past surgical procedures

● Family History = includes conditions in the immediate family (parents, siblings, and
patient’s children) that may be passed down genetically

● Social History = includes lifestyle choices (smoking, drinking, illicit drugs); includes living
situation, occupation, marital status, diet, exercises, etc.
Review of Systems

The Review of Systems (ROS) is an organized review of the

patient’s organ systems which indicates signs or symptoms
the patient may or may not be experiencing or recently
experienced. This part of the patient encounter may flow
fast since the provider typically asks these questions back-
to-back with the patient typically responding only with either
a “yes” or a “no.”

The ROS is phrased as a list of positive (+) and negatives (-).

● Positive means the patient is experiencing and negative means the
patient is not experiencing.
Details of the symptoms are not included in the ROS section.
● Some of the “details” may be included within your HPI.
● All symptoms mentioned in the HPI must also be included within the ROS.
● The ROS findings should never contradict symptoms discussed in the HPI.

Remember: The ROS is part of the “Subjective” meaning the findings are from the patient’s perspective.
Objective
Objective Information Includes

RESULTS FROM PROVIDER

VITAL SIGNS PHYSICAL EXAM ORDERS STATEMENT

Where “subjective information” was

about personal opinions, perceptions,
assumptions, interpretations, beliefs, etc.
from the patient’s point of view,
“objective information” deals with
observations, testing, results, etc from the
provider’s point of view.
Vital Signs

blood pressure heart rate respiratory rate

temperature oxygen saturation

NOTE: Some providers also prefer height, weight, and body mass index (BMI) to be included with the
vitals.
Physical Exam

The provider will tailor their physical exam to

each individual patient based on their Chief
Complaint and Medical History.

The physical exam is an examination of the

patient’s body for signs of disease or injury.

There are several different types of exams that a

provider may conduct. It is important for you to
be able to identify the type of exam they are
verbalizing and which body system the exam
findings should be documented in.
Diagnostic Tests: Labs (Reviewed vs. Ordered)

Labs help determine a diagnosis, an appropriate treatment plan, to verify current

treatments are effective, and to monitor conditions over time.

LABS REVIEWED LABS ORDERED

● During the patient encounter, the ● During the patient encounter, the
provider will review the results of recent provider may order labs that are
labs with the patient and discuss a needed. Sometimes these labs can be
treatment plan, if needed. done within the facility and sometimes
the patient must go to another facility.
● Labs reviewed during the patient visit are
documented in the SUBJECTIVE section ● These labs are documented within the
of the SOAP Note. Typically, in the HPI PLAN section of the SOAP Note as they
paragraph of the disease/condition or correspond with a treatment plan for a
chief complaint. It could also be tagged disease/condition.
again in the PLAN section as it relates to ○ For example, a patient may have
medical decision making of that recently started a medication to
disease/condition. help lower their cholesterol; so, the
provider wants to see how
effective the medication is.
Assessment
Assessment

Subjective Objective
Assessment
Complaints Findings
(Diagnosis)
(HPI & ROS) (Physical Exam)

The “Assessment” is the provider’s impression

or diagnosis based on the patient’s
complaints and physical exam findings.

Each diagnosis becomes a permanent part of

that patient’s medical history, so it is important
to document the Assessment accurately.
Assessment: ICD-10

ABOUT ICD-10
● ICD-10 refers to the 10th edition of the International Classification of Diseases, which
is a medical coding system chiefly designed by the World Health Organization
(WHO) to catalog health conditions by categories of similar diseases under which
more specific conditions are listed, thus mapping nuanced diseases to broader
morbidities.

● The US version of ICD-10, created by the Centers for Medicare & Medicaid Services
(CMS) and the National Center for health Statistics (NCHS), consists of 2 medical
code sets:
○ ICD-10-CM (Clinical Modifications AKA Diagnoses)
■ As a DeepScribe Scribe, these are the only “codes” you will search for
○ ICD-10-PCS (Procedure Coding System) [only used for inpatient procedures]

● ICD-10 diagnosis codes are required for claims submission. Without them, a
provider cannot get paid by health plans/insurance companies.
Assessment: ICD-10 Structure

ICD-10-CM codes consists of 3 to 7 characters:

● The 1st character is always a letter and it is indicative of the category to which the
code is classified.
● The 2nd and 3rd characters are numbers.
● The 4th - 7th characters can be numbers or letters

E11.9
Endocrine, Nutritional, and Metabolic Disease
Type 2 Diabetes Mellitus
Without complications
Assessment: ICD-10 - Unspecified Codes

You should always select the most appropriate and accurate ICD-10 code.
The goal is for the diagnosis code to adequately reflect what’s happening
with the patient, including specific body parts if needed).

Sometimes, you do not have enough information provided to select a higher

level code, and you have to use an “unspecified” code.

“Unspecified” codes (usually with a 9 or a 0 as the last character) are used

when the information in the medical record is not available for coding more
specifically.

Examples:
J32.9 Chronic sinusitis, unspecified
L40.9 Psoriasis, unspecified
N17.9 Acute kidney failure, unspecified
M06.029 Rheumatoid arthritis without rheumatoid factor, unspecified elbow
Plan
Plan

The plan often includes one or

of the following:
● Medications
The plan is the treatment
care or decision(s) that ● Referrals for specialty
address each diagnosis. evaluation or
labs/imaging

ASSESSMENT ● Education or counseling

“What does this patient about instructions for at
have?
home care, potential side
PLAN effects of medications,
What should be done lifestyle changes, etc.
about it?
● Follow-up visit time frame
Example SOAP Note
Example SOAP Note

Example DeepScribe Note

Most Electronic Health Records

(EHRs) follow a similar format for
the note structure.

As a Medical Scribe, it is
essential that you know in which
section of the SOAP note the
medical information is
documented.
 The End

Brief Overview of a SOAP Note