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HLHS101 Chap 2 Mod 3

HLHS101 Module 3/Chapter 2 Flashcards

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)
Created by: Lehill