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Week 5

Fundamentals Chapter 23

Purpose of Medical History To obtain a basis for all treatment given
SOAP Subjective Objective Assessment Plan
Medical History Patient's personal history
Family History Families medical history
Social History Partner status, habits, use of substances
Subjective what the patient tells us
Objective What is measured
Assessment Diagnosis
Plan Treatment, medication, referral
ROS Review of Symptoms
HIPPA Health Insurance Portability and Accountability Act
If it isn't documented...... .....It didn't happen
What color ink is acceptable for medical charts Blue or Black ink
Mistake in written chart single line, initials, and date
Patients name must be on every sheet in paper chart
Before rooming patient..... Check the chart and Ready the room
First Question you should ask a patient during screening... Do you have any allergies, do you have any medication allergies?
Created by: MissTina