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Chapter 2 MED TERM
Introduction to Health Records
| Question | Answer |
|---|---|
| Where can health records be found? | Paper charts or Electronic health record (EHR) |
| What does SOAP stand for? | Subjective, Objective, Assessment, and Plan |
| What does Subjective mean in SOAP? | These are any problems or issues a patient is having |
| What does Objective mean in SOAP? | Data that a health care provider collects |
| What are the general objective terms? | Things that are seen, heard, felt, and descriptions of anything that was observed |
| What is the Assessment part of SOAP? | This is the combination of the two, subjective/objective, in which the information gathered leads to a diagnosis. |
| What is the Plan part of SOAP? | This is where the health provider gives a recommendation to the patient as of what to do to solve their current medical issue |
| What is a physician? | A person who graduated from a medical school and is providing health care |
| What is a pediatrician? | This would be a physician that specializes in caring for children |
| What does this symbol mean? ♂ | Male |