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ch. 2

Medical Records

TermDefinition
Chief Complaint The main reason for the patient's visit
Transverse divides the body from top to bottom
sagittal divides the body in slices right to left
coronal divides the body into slices from front to back
The four general parts of a medical note the acronym SOAP stands for Subjective Objective Assessment Plan
Past surgical history any of the patient's past surgeries
Clinic note documents a visit to a clinic written by a medical professional
Operative report documents a surgery in detail written by a Surgeon
Radiology report Explains reason for image, how image was performed, what was seen on image, and the radiologist's assessment; sometimes a recommendation. written by a radiologist
Admission summary Documents the admission of a patient to the hospital written by a hospital medical professional
Created by: ncardoza