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Chapter 2

QuestionAnswer
SOAP Method Subjective: What the patient says Objective: What the tests reveal Assessment: the analysis of the subjective and objective information; performed by the health care provider Plan: the course of action for the patient
Dx diagnosis
DDX differential diagnosis
Tx treatment
Rx prescription
Hx history PMHx - past medical history FHx - family history
H&P history and physical
CC chief complaint
HPI history of present illness
ROS review of systems
PE physical exam
PCP primary care provider
NKDA no known drug allergies
Created by: Mary Bertrand
 

 



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