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Chp 2 Flashcards

TermDefinition
SOAP Method Subjective, Objective, Assessment, & Plan
What is included in the Subjective section of a health record? The main reason for the visit, the timing of the problem, previous surgeries/medical problems, family health history, & current allergies and medications
Acute it has just started recently or is a sharp, severe symptom
localized stays in a certain part of the body
What is included in the Plan portion of a health record? Medicine or home remedies, prescribers course of treatment
What is included in the Objective portion of a health record? Special images taken of patient, diagnostic tests ran through laboratories, and other data gotten through the provider
What is included in the Assessment portion of a health record? The diagnosis and provider may offer other a differential diagnosis
etiology the cause
Clinic Note A handwritten, electronic, or dictated note a healthcare professional uses to document a visit in an office setting
Consult Note A note from a specialist that is sent to a primary care provider for a patient
Created by: CarlyLawson25
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