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Chapter 2 Study 10

Terms & abbreviations

QuestionAnswer
What the patient is experiencing & medical history in SOAP method is? (patient story) Subjective
Collecting patient's physical exam, imaging and laboratory finding are what in the SOAP method? (measurable data) Objective
Diagnosis,or identification is what method in SOAP? (Clinical Logic) Assessment
The course of action in SOAP method is... (Action Steps) Plan
What is the term for a recent sharp, serve symptom? Acute
What is the term for something that has been going on for a while? Chronic
Term for getting worse? Exacerbation
Farther away from the center is? Distal
What is the abbreviation for Electronic Health record? EHR
What type of documentation format is used for consultation notes? SOAP
What is the documentation method used for charting medical records? SOAP
What parts of the SOAP method use documentation and an admission summary? Objective & Subjective
Created by: Gisselleirias
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