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Medical Terminology

Intro into Health Records

QuestionAnswer
What is the S.O.A.P Method? S- Subjective, O-Objective, A-Assessment, P-Plan
What is the meaning of exacerbation? It keeps getting worse
What information is typically found in a patient's health records? -What medication was prescribed to the patient -When the patient is supposed to follow up -what the patient had
What does the Plan part of the S.O.A.P method provide? A course of action that is consistent with the provider's assessment
What is the meaning of palliative? To treat the symptoms, but not actually getting rid of the cause
Where would you find information on any past surgery the patient has had on their health records? Past surgical history
What abbreviation would you use for taking medicine at night? QHS
What term would you use if a patient is responsive and interactive? Alert
What does it mean if a finding on the patient is benign? Safe
When in the S.O.A.P method would the assessment come into place? Once all the facts from the patient are recorded and data is collected, they are put together to reach a conclusion, ending in a diagnosis
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