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Medical Terminology
Chapter 2, Terms an Definitions
Term | Definition |
---|---|
Operative Report | Documents a surgery |
Clinic Note | Documents a patient visit in an office setting |
Discharge Summary | Documents a patients admission and hospital stay |
Consult Note | A document sent to a primary physician, usually a specialist, to give an opinion on a more challenging problem |
Chief Complaint | The main reason for a visit |
Review of Systems | Any symptoms not directly related to the main problems |
Subjective (SOAP Method) | What the patient says |
Objective (SOAP Method) | What the test reveal |
Assessment (SOAP Method) | The analysis of the subjective and objective information, performed by the health care provider |
Plan (SOAP Method) | The course of action for the patient |