Fundamentals Chapter 23
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Purpose of Medical History | To obtain a basis for all treatment given
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| SOAP | Subjective Objective Assessment Plan
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| Medical History | Patient's personal history
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| Family History | Families medical history
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| Social History | Partner status, habits, use of substances
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| Subjective | what the patient tells us
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| Objective | What is measured
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| Assessment | Diagnosis
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| Plan | Treatment, medication, referral
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| ROS | Review of Symptoms
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| HIPPA | Health Insurance Portability and Accountability Act
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| If it isn't documented...... | .....It didn't happen
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| What color ink is acceptable for medical charts | Blue or Black ink
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| Mistake in written chart | single line, initials, and date
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| Patients name | must be on every sheet in paper chart
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| Before rooming patient..... | Check the chart and Ready the room
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| First Question you should ask a patient during screening... | Do you have any allergies, do you have any medication allergies?
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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