Chapter 5: Medical Terminology Flashcards
1
Q
Name the components of medical chart organization
A
Demographics and insurance Flow sheets Physician orders Visit notes Laboratory notes Radiology notes Consultant notes Other communications
2
Q
What is the SOAP note?
A
SOAP note is a method employed by healthcare professionals to create patient charts. Consists of the following:
S= Subjective (what the pt tells you)
O= Objective (info from PE, labs and radiology)
A= Assessment (Dx and DDx)
P= Plan (tx, further tests, etc)
3
Q
CC
A
chief complain of pt
4
Q
HPI
A
history of present illness
5
Q
ROS
A
review of systems
6
Q
PMHx
A
past medical history
7
Q
PSHx
A
past surgical Hx
8
Q
SHx & FHx
A
social and family Hx
9
Q
NKDA
A
no known drug allergies
10
Q
PE
A
physical exam
11
Q
(+)
A
present
12
Q
(-)
A
absent or negative
13
Q
nl
A
normal
14
Q
wnl
A
within normal limits
15
Q
CBC
A
complete blood count
