Lecture 10 Flashcards
(26 cards)
Why do we keep clinical records?
- Have all details to best diagnose
- Monitor change
- Monitor care approach over time
- Legal record of events
- Research
- Data management and tracking
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
Subjective part of SOAP
- Captures patients perspective on their condition
- Includes chief complaint, symptoms and current health status
- Use patients own words enclose in quotes
Objective in SOAP
- Factual observations from clinician
- Include vital signs, lab results, physical examination findings and any diagnostic tests
- Clear, concise and measurable data
Assessment in SOAP
- Analyses information from subjective and objective section
- SYnthesize findings to form a clinical judgment about pratients condition
- Consider potential diagnoses, rule out unlikely causes and assess severity of problem
Plan in SOAP
- Treatment recommendations
- Medications
- Referrals to specialists
- Patient education instructions
SOAP(OP) - Extendid
Objective Changes
- Post treatment changes
- Revisit pre-treatment assessment
Planned:
- Follow up appointments
Abbreviation for - 1 time per week
1x/w
Abbreviation for - 2 times per week for 3 weeks
2xw/3w
Abbreviation for - 2-4 times per month
2-4x/m
Abbreviation for - abduction
abd
Abbreviation for - Abnormal
abn
Abbreviation for - active assisted range of motion
AAROM
Abbreviation for - Active range of motion
AROM
Abbreviation for - Activities of daily life
ADL
Abbreviation for - Adduction
add
Abbreviation for - Adjustment
adj
Abbreviation for - afternoon
pm
Abbreviation for - alternating hor/cold
alt h/c
Abbreviation for - anterior
ant
Abbreviation for - anterior superior iliac spine
ASIS
Abbreviation for - anterior-posterior
AP
Abbreviation for - as soon as possible
ASAP
Abbreviation for - asymmestrical
asym
