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medical term cards

TermDefinition
What are acceptable methods of documentation in a pt chart? Handwritten, electronic, and dictated
SOAP is the acronym for what? Subjective Objective assessment, plan
PCP Primary care Provider
The assessment is also known as? Differential diagnosis
Subjective color Blue
Chief Complaint Main reason for visit
Social History a record of habits like smoking drinking etc
Review of systems A description of your body systems in order to discover any symptoms not directly related to the main problem.
PACU Post Anesthesia care Unit
CCU Coronary Care Unit
Created by: user-2044099
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