Medical Auditing Practice Exam

In the SOAP and CHEDDAR formats, where is the patient's history generally documented?

1. The O in SOAP and the E in CHEDDAR

2. The S in SOAP and the H in CHEDDAR

3. The A in SOAP and the D in CHEDDAR

4. The P in SOAP and the D in CHEDDAR

The correct answer is: The S in SOAP and the H in CHEDDAR

The correct answer highlights that the patient's history is typically documented in the 'S' for Subjective in the SOAP format and the 'H' for History in the CHEDDAR format. In the SOAP method, the Subjective section is where the patient's own description of their condition, symptoms, and history is captured. This includes insights into their feelings, experiences, and any pertinent information that the patient shares about their health status. It provides the clinician with an understanding of the patient's perspective, which is crucial for accurate diagnosis and treatment. In the CHEDDAR format, the History section serves a similar purpose. This section focuses on gathering comprehensive background information on the patient's medical history, contributing to an understanding of their current health issues. This allows healthcare providers to consider past medical events, treatments, and associated factors that may influence the current health status. Both formats prioritize the patient's history as foundational for clinical decision-making, ensuring that healthcare professionals have a well-rounded view of the patient’s health before proceeding with further assessment or treatment.