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HLHS101 Chap 2 Mod 3
HLHS101 Module 3/Chapter 2 Flashcards
| Term | Definition |
|---|---|
| SOAP meaning | Subjective, Objective, Assessment, and Plan (Smartbook page 54) |
| S in SOAP definition | Subjective - what the patient describes, including histories, duration of aliment, intensity, and other necessary facts (Smartbook page 54) |
| O in SOAP definition | Objective - Labs, images, and physical exams at MDO (Smartbook page 54) |
| A in SOAP definition | Assessment - Using the labs, images, and notes from exams, MD diagnoses or gives a list of possible explanations (Smartbook page 54) |
| P in SOAP definition | Plan - MDO uses assessment to devise a course of treatment (Smartbook page 54) |
| EHR | Electronic Health Records - includes all notes, records, lab results, and x-rays (Smartbook page 53) |
| Exacerbation | Getting worse (Subjective term, Smartbook page 75) |
| Malaise | Not feeling well (Subjective term, Smartbook page 75) |
| Auscultation | Listen (Objective term, Smartbook page 77) |
| Palpation | Feel (Objective term, Smartbook page 77) |
| Differential Diagnosis | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam (Assessment Term, Smartbook page 79) |