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Chapter 2
Word parts, terms and/or abbreviations from chapter 2.
Term | Definition |
---|---|
S (In SOAP) | Subjective: What the patient says |
O (In SOAP) | Objective: What the tests reveal |
A (In SOAP) | Assessment: The analysis of the subjective and objective information; performed by the health care provider |
P (In SOAP) | Plan: The course of action for the patient |
Clinic Note | Contains all parts of SOAP and is organized accordingly. Also includes patient information, medications patient is on, and patient allergies. Presents patients family history, tests results and interpretations, and f/u (follow up) |
Consult Note | When one health care provider asks another who is a specialist to evaluate patient. Contains all parts of SOAP. |
Emergency Department Note | Health record from emergency department. Short and contains only needed information. Contains all parts of SOAP. |
Admission Summary | Written upon hospital admission. Heavily subjective and objective information, might include or even combine assessment and plan. |
Discharge Summary | Notes when and why patient was admitted. Assessment is the most important part so it goes first. All parts of SOAP included. |
Operative Report | Concise and tell story of surgery. Does not include test results or vitals. Assessment goes first as it is most important. If preoperative and postoperative are the same, they will be one entry. |