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HLHS101-Ch 2
Acquiring Medical Language Chapter 2
Term | Definition |
---|---|
S O A P | S: Subjective O: objective A: Assessment P: Plan |
Subjective data | how a patient experiences and personally describes the problem, as well as personal and family medical histories. The problem in the patient's own words. |
Objective data | comprise the patient's physical exam, lab findings, and imaging studies |
Assessment | Could be a diagnosis, an identification of a problem or a list of possibilities for the diagnosis, which is known as a differential diagnosis. |
Plan | course of action consistent with the assessment. could be a treatment with medicine or a procedure. could also consist of collecting more data to help arrive at a more accurate diagnosis. |
Color Codes for SOAP | S: blue O: red A: yellow P: green (note: sometimes assessment and plan run together; these instances appear in light green) |
chief complaint | the main reason for the patient's visit |
BID | twice daily |
TID | three times daily |
QID | four times daily |