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Chapter 2 MED TERM

Introduction to Health Records

QuestionAnswer
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
Created by: bk282