Lecture 3 Flashcards
(281 cards)
SOAP
S- subjective
O- objective
A- assessment
P- plan
acronym for medial record
subjective info
problem in patients own words, duration, quality, and what makes better/worse
objective info
labs, tests results, and assessment findings
assessment info
what provider sees, can include a diagnosis, identificaiton of problem or list of potential diagnoses
plan info
course of action and treatment options
know general subjective terms
acute v chronic
abrupt
febrile v afebrile
malaise
progressive v exacerbation
symptom
lethargic
genetic or hereditary
general objective terms
seen:
alert- can answer questions
oritented- person, place, time
general objective terms
heard:
auscultation: to listen
percussion: to tap on something
general objective terms
felt:
palpation: to feel
general objective terms
description of observations:
marked- its notable (something is abnormal)
unremarkable- normal
Assessment
characteristics of assessments:
- combination of subjective and objective data
- helps to determine the diagnosis
- no single cause —> a differential diagnosis is given and a list of most likely causes
general assessment terms
morbidity
suffering from a disease or condition
general assessment terms
occult
hidden
general assessment terms
lesion
abnormal skin condition
general plan terms
palliative
treatment (not to cure) of symptoms
general plan terms
discharge
leaving after treatment
general plan terms
observation
to be watched over a period of time to see if anything happens/tests are done
general plan terms
prophylaxis
provide treatment to prevent illness
body planes and oritentation
anatomical position
standing straight with palms forward
*always assume patient is in this position unless otherwise noted
body planes and oritentation
proximal
closer to center
body planes and oritentation
distal
furthest away from the center
body planes and oritentation
cranial/superior
toward head
body planes and oritentation
caudal/inferior
lower/under head
body planes and oritentation
supine
lying on back