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Chapter 2

Introduction to Health Records

TermDefinition
What is the SOAP method? subjective - what the patient is feeling in their own words objective - data from tests, labs, or procedures assessment - a diagnosis, identification of a problem, or list of possibilities for the problem plan - course of action based on the assessment
acute sudden or sharp
afebrile to not have a fever
malaise not feeling well
lethargic a decrease level of conciousness
PICU pediatric intensive care unit
SICU surgical intensive care unit
PACU post-anesthesia care unit
pre-op before surgery
post-op after surgery
Created by: marklynnkeal
 

 



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