Week 5 Word Scramble
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Question | Answer |
Purpose of Medical History | To obtain a basis for all treatment given |
SOAP | Subjective Objective Assessment Plan |
Medical History | Patient's personal history |
Family History | Families medical history |
Social History | Partner status, habits, use of substances |
Subjective | what the patient tells us |
Objective | What is measured |
Assessment | Diagnosis |
Plan | Treatment, medication, referral |
ROS | Review of Symptoms |
HIPPA | Health Insurance Portability and Accountability Act |
If it isn't documented...... | .....It didn't happen |
What color ink is acceptable for medical charts | Blue or Black ink |
Mistake in written chart | single line, initials, and date |
Patients name | must be on every sheet in paper chart |
Before rooming patient..... | Check the chart and Ready the room |
First Question you should ask a patient during screening... | Do you have any allergies, do you have any medication allergies? |
Created by:
MissTina
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