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Health records

Flash cards for health record's terminologies

QuestionAnswer
What are the four general parts of a medical note? 1. Subjective 2. Objective 3. Assessment 4. Plan
In what part of a medical note is written the patient name, DOB, and FHx? Subjective
In what part of the medical note, a medical staff will find f/u tests? Plan
Is a note from a visit to a specialist, a Clinic note or Consult note? Consult Note
Which form does not follow the SOAP note format? a) Emergency department note b) Prescription B.
Mr. Smith is at the CCU after a heart transplant surgery. Is Mr. Smith staying at? a) Central Care Unit b) Coronary Care Unit B
What does NKDA abbreviation stands for? No known drug allergies
In what part of the SOAP note format could we find the Dx, or DDx? Assessment
In what part o the SOAP note format could we find the T, BP, HR, RR, Ht, Wt, and BMI of a patient? Objective
Mr. Smith's Cardiologist gave a prescription to take his 40 mg Atorvastatin QHS, PC. How is he supposed to take this medication? a) At night after meals b) Daily after meals A
Created by: yadiramatos
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