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Medical Terminology
Question | Answer |
---|---|
What does the acronym SOAP stand for? | SOAP stands for the 4 different types of information documentation in a medical note. S. Subjective O. Objective A. Assessment P. Plan |
What does: HR+RR+BP+T=VS stand for | Heart rate + respiratory rate + blood pressure + temperature = vital signs |
SICU stands for | Surgical intensive care unit |
EHR stands for | Electronic Health Records |
DDx stands for | Differential diagnosis |
NPO stands for | nil per os (nothing by mouth) |
What does each line of a prescription include? | Line 1:name and strength of the medicine Line 2:marked "Sig" contains the patient's instructions (usually in medical language) Line 3: marked "Dispense" tells the pharmacist how much medicine to give Line 4: how many refills Last line: HCP's signature |
What does the "S" in SOAP stand for | Subjective, which is the patient's experience and personal description of the problem. |
What does the "O" in SOAP stand for | Objective, which is the patient's physical exam, lab findings, and image studies. |
What does the "A" in SOAP stand for | Assessment, a diagnosis, a list of possibilities (DDx), or and identification of a problem. |
What does the "P" in SOAP stand for | Plan, or the course of action, which can be a treatment or they may need to be more data collected. |