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Chapter 2 (M01)

Intro to Health Records (M01 Discussion)

TermDefinition
Subjective The problem in the patient's own words.
Objective Comprises of the patient's physical exams, any laboratory findings, and imaging studies performed at the visit.
Assessment Formulates a logical analysis.
In what part of SOAP does this example belong? "FOLLOW-UP: Appointment- PCP (Dr. Primo) in 1 week." Plan
Sagittal plane Divides the body in slices right to left.
Discharge Summary Includes: how the patient felt when admitted, what happened during the patient's stay in the hospital & what kind of follow-up the patient will have. This documents a longer stay at the hospital.
PERRLA Pupils are equal, round and reactive to light and accommodation.
DDx Differential Diagnosis
Build a medical term from the information provided: Root: Path/o Suffix: -logist Pathologist
QHS At night
Created by: amybarkat
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