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Chapter 2
SOAP, Records, & Abbreviations
| Term | Definition |
|---|---|
| QID means... | four times a day (quater in die) |
| QHS means... | each night (quaque hora somni) |
| SOAP is an abbreviation for... | S-subjective, O-objective, A-assessment, P-plan |
| NKDA is an abbreviation for... | no known drug allergies |
| The 4 general parts of a medical record are called... | the SOAP note |
| Which part of the medical record includes the patients chief complaint in their own words? | Subjective |
| WNL means... | within normal limits |
| SIG means... | label (signa) |
| A record taken after the patient has reported their health history and has been physically examined is called... | an Admission Summary |
| The sagittal plane divides the... | right and left sides of the body |