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Module 1

Chapter 2

QuestionAnswer
What does EHR stand for? Electronic health record
What does the acronym SOAP stand for? Subjective, Objective, Assessment, Plan
What does the subjective section of a SOAP note tell about a patient? Patient's personal story of the health issue
What does the objective section of a SOAP note consist of? Data collected during a provider's interaction with the patient
What are four things a provider observes when interacting with a patient? How they look, sound, feel, and smell
What is found in the assessment section of a SOAP note? Diagnoses, opinions, severity of problem, chance of improvement
What is in the plan section of a SOAP note? Provider recommendations, medicinal or home remedies, surgery, wait for more data collection
What is a "differential diagnosis"? Thought process and possible causes for determining the patient's problem
What does the abbreviation HEENT stand for? Head, eyes, ears, nose and throat
What is a SOAP note? The structure of medical notes, a way of thinking
Created by: phunt27
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