Note Organization - Phase I

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Learning your Tools

Phase I

Note Organization

TIPS/RESOURCES

EXAM

INDEX

INDEX

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QUIZ

A&P Organization

A&P

RESULTS

ROS

HPI METHODS

HPI

SOAP FORMAT

INTRODUCTION

A note with proper organization will flow well and be easily readable.The informationwill make sense in the section it was placed in.

Lack of organization can impact clarity, document integrity, and result in an error during a Quality audit.

A Well-organized note enables your provider to quickly find the information they need within the patient's note.

to note organization

INTRODUCTION

First let's talk about....

Subjective, Objective, Assessment, and Plan

SOAP Format

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Of a SOAP Note

Components

The typical components of a SOAP Note are..

• Chief Complaint
• History of Present Illness
• Review of Systems
• Past Medical, Surgical, Family, and Social History
• Physical Exam
• Medical Decision Making/Results
• Assessment/Treatment Plan

• The HPI will include any patient complaints, any symptoms, prior and current medications, prior and current treatments, medical history, surgical history, family history, and social history.

• Any relevant information coming from the patient (subjective) needs to be included in the HPI.

• This will consist of experiences, personal views, and feelings of the patient. The HPI is the information we would not know unless the patient or patient's family told us.

History of Present Illness

HPI

The HPI is a chronological description of the progression of a patient's present illness from the very first sign and symptom through to the present, as well as any other signs and symptoms.

Hover over each of the icons on the right to explore!

OLDCARTS

hpi rAINBOW

METHODS

HPI Organization

Example of OLDCARTS Method

Knowledge Check

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• The ROS contains ONLY subjective information, symptoms the patient reports, and is typically stated by the patient.
• This is often pulled into the note via iPhrase, which assists with organization of the information according to the provider's preferences in the Clinician's Instructions.
• We should always refer to the Clinician's Instructions for guidance on organization and formatting of the ROS.
• The Review of Systems DOES NOT include exam findings or diagnoses.

ROS

Review Of Systems

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Physical Exam

PE

The Physical Exam is objective information stated by the provider either while the exam is taking place or in conversation/dictation following the visit.

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The Results section should include labs, imaging, and testing as requested by the clinician. This section will only contain objective information coming from the provider and is typically mentioned as part of the dictation.

Results

Introducing The

Knowledge Check

Assessment

Plan

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• The Assessment is the clinician's summary and/or diagnosis based on both the subjective details and objective Exam and Results for the patient.

• Formatting of the Assessment varies between providers so we must refer to the Clinician's Instructions to determine the appropriate formatting.
• Possible formats may include an Assessment paragraph as verbalized by the provider, a summary or list based on the ambient conversation between patient and provider, or just an Assessment header stating the diagnosis.

• The Plan will contain any information regarding treatments for the patient going forward. This will include any patient instructions, future treatments, imaging or testing, referrals, surgical planning, and follow-up information.

• Formatting of the Plan varies between providers, so ensure you are referring to the Clinician's Instruction for guidance.
• Possible formats may include paragraph summaries or lists based on ambient conversation and/or dictation. This section often uses iPhrases!

Assessment and Plan

A & P

• Patient instructions/education - especially conservative measures
• Referrals and follow-up information
• Patient compliance - "The patient understands and agrees with the treatment plan."

Very similar to the HPI Rainbow Pyramid, we have an A & P Rainbow method that can be used to help organize the Assessment and Plan when there are no specific details regarding this section in the Clinician's Instructions.Using this method, we would organize the Assessment and Plan information in the following order:

• Impression/Assessment
• Differential diagnosis
• Labs/orders/imaging to rule out differentials
• Treatments/procedures/new medications - may include risks, benefits, and alternatives statement

the A&P

Organizing

Helpful Hints & Resources

Recap

Need a brief summary of everything we discussed today? Click the icon below for a Note Organization recap!

Resources

Click the icon below to access some resources you can download and refer to later as needed.

Need Help?

Are you having difficulty differentiating between HPI information and Plan details? Click the icon below!

CLICK TO BEGIN

Now let's take a brief quiz to review what you have learned today! You must clear the quiz with a score of 80% or better to move on to the next module!Take your time, don't stress, and try to implement what you have learned. Best of luck to you!

Note Organization quiz

For any questions or concerns regarding Phase I of your Training, please reach out to Nikki Dease on Teams or Nikki.dease@cognizant.com

For Completing your Phase I Note Organization Module

THANK YOU

Example ROS

The Review of Systems can contain positive and/or negative responses reported or denied by the patient during the encounter.This can be free-typed based on the verbalized information, pulled in with an iPhrase and edited per the verbalized information, or include only a blanket statement, dependent upon the directions given by the Clinician's Instructions.

Subjective/Objective information Medical decision-making and treatment Plan informationVerbalized in dictation or ambient conversationAll treatments that occurred during visit or will occur in future

Objective information from providerLabs, imaging, testing, etc.Verbalized in dictation or ambient conversationLikely free-typed or pulled in with iPhrase

Objective information from providerVerbalized in dictation or while exam is taking placeSigns observed by clinicianLikely pulled in with iPhrase

Subjective information from patient or patient's familyHistory of everything up until time of the visitComplaints and symptomsFeelings-based

A & P

Results

Exam

HPI

Note Organization Recap

Example Physical Exam

The Exam should include positive and/or negative findings observed by the clinician during the encounter.This can be free-typed based on the verbalized information or pulled in with an iPhrase and edited per the verbalized information dependent upon the directions given in the Clinician's Instructions.

Example Results

The way to document Results varies between providers, so we must always consult the Clinician's Instructions for guidance on how to document this section appropriately.The Results may be free-typed based on the verbalized information, pulled in with an iPhrase and edited per the verbalized information, or even requested by the provider to be omitted as the information is already documented in the EHR by the clinic staff. Refer to the Clinician's Instructions for appropriate workflow!

The Plan should include information provided by clinician regarding the patient's treatments that occurred during the visit and the plan going forward.Sentences in the Plan start with words like I or We and have verbs in the future tense (will send, will order, will test), and may also include words in the past tense to discuss what occurred during the visit ( I explained, instructed, educated). Examples include:

• I will order an x-ray for further evaluation.
• We will send in a prescription for lisinopril.
• I explained the surgical risks and benefits.

HPI vs. Plan Information

HPI

The HPI should include information provided by the patient or patient's family regarding their current and past medical history. The HPI can also include information provided by the clinician as an introduction or interval history, prior to entering the room with the patient.Sentences in the HPI start with words like The patient, He/she, They, This pain, etc. and are typically in the past or present tense. Examples include:

• The patient complains of pain.
• The pain is located anteriorly.
• She had difficulty ambulating yesterday due to pain.

Plan

Download these resources for later!