Chapter 2 Vocab Flashcards
What does the acronym SOAP mean?
Subjective, Objective, Assessment, and Plan
Why do we use the acronym SOAP?
To understand the four general parts of a medical note
Subjective part of a medical note
The problem in the patient’s own words.
What does the subjective part of a medical note include?
The duration of the problem, the quality of the problem, and any exacerbating or relieving factors for that problem.
What is the objective data in a medical note?
The patient’s physical exam, any laboratory findings, and imaging studies performed at the visit.
What is the assessment of a medical note?
The logical analysis that a health providers formulates, after gathering all the pertinent information.
What are some examples of what an assessment could be in a medical note?
A diagnosis, an identification of a problem, or a list of possibilities for the diagnosis (differential diagnosis)
What is a plan of a medical note?
A course of action consistent with his or her assessment
What are some types of plans that would be in a medical note?
Treatment with medicine, procedure, collecting more data to arrive at a more accurate diagnosis, etc
It just started recently or is a sharp, severe symptom
It has been going on for a while now
It is getting worse
All of the sudden
To have a fever
To not have a fever
Not feeling well
More and more each day
Something a patient feels
Not related to this specific problem
A decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick
It runs in the family
Able to answer questions; responsive; interactive
Being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is “oriented x 3”
It really stands out
Another way of saying normal
To hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument
Another way of saying assessment
What the health care professional thinks the patient has
A list of conditions the patient may have based on the symptoms exhibited and the results of the exam
Dangerous; a problem
To be getting worse
To get better or improve; most often used when discussing cancer; remission does not mean cure
No known specific cause; it just happens
Stays in a certain part of the body
Systemic / Generalized
All of the body (or most of it)
The risk for being sick
The risk for dying