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Chapter 2

TermDefinition
SOAP S= subjective - what the patient says O=objective - what tests reveal A= assessment - analysis of the subjective and objective info P=plan - course of action
chief complaint main reason for the patient's visit
review of systems description of individual body systems in order to discover any symptoms not directly related to the main problem
social history a record of habits like smoking, drinking, drug abuse, and sexual practices that impact health
A&O alert and oriented
PERRLA pupils are equal and reactive to light and
NAD no acute distress
CTA clear to auscultation
RRR regular rate and rhythm
NOS not otherwise specified
Created by: skye1214
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