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Med Term: Session 3

SOAP, Records, and Abbreviations

TermDefinition
The SOAP Method A pattern used in medical notes to maintain a consistent organization and layout.
Subjective, Objective, Assessment, Plan The four parts of the SOAP Method
Clinic Note A documentation of a patient's visit in an office setting
Consult Note A note from a visit to a specialist or consultant
Admission Summary A detailed summary of a patient's medical history and physical exam upon admittance to a hospital
Operative Report A report that documents in detail the procedure used in an operation
Sig The second line of a prescription, which contains patient's instructions
Dispense Tells the pharmacist the amount of medicine to give a patient
PO The abbreviation for the administration of a medicine by mouth
SC The abbreviation for an injection under the skin, but not into a vein
Created by: ksmith711