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Chapter 2

Medical Notes and abbreviarions

TermDefinition
4 general parts of a medical note Subjective Objective Assessment Plan
Subjective Part (of a medical note) - the problem in the patient’s words (experiences personal/family history, duration, quality and any exacerbating or relieving factors of the problem)
Objective data (of a medical note) - the patient’s physical exam, any lab findings, and imaging studies performed at the visit
Assessment (of a medical note) - a logical analysis by the health care provider giving a diagnosis or differential diagnosis
Plan (of a medical note) - a course of action consistent with the assessment (could be a treatment or collecting of further data for a more accurate analysis)
CCU Coronary Care Unit
ECU Emergency Care Unit
PICU Pediatric Intensive Care Unit
SICU Surgical Intensive Care Unit
PACU Post Anesthesia Care Unit
L&D Labor and Delivery
Created by: tmoses18
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