BASIC MEDICAL DOCUMENTATION Flashcards

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1
Q

BASIC MEDICAL DOCUMENTATION (5)

A

INFO ABOUT PT MEDICAL HISTORY AND PRESENT CONDITION

USED FOR PATIENT AND STAFF EDUCATION AND RESEARCH

USED AS COMMUNICATION TOOL AND LEGAL DOCUMENT

PROVIDES A MAP OR PLAN FOR CONTINUITY OF CARE

SUPPORTING DOCUMENTATION FOR BILLING AND CODING PURPOSES

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2
Q

SOAP DOCUMENTATION

A

SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN

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3
Q

SUBJECTIVE (SOAP)

A

CHIEF COMPLAINT

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4
Q

OBJECTIVE(SOAP)

A

MEASUREABLE DATA - VITALS, LABS, MEASUREMENTS

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5
Q

ASSESSMENT (SOAP)

A

MEDICAL DIAGNOSIS

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6
Q

PLAN (SOAP)

A

FOR TREATMENT

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7
Q

PATIENT INTERVIEW

A

FIRST STEP IN EXAM PROCESS
ESTABLISHES A RELATIONSHIP
EXCHANGE OF INFO

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8
Q

reason for appointment

A

establish - “why are you here today?”
routine checkup, follow up, established pt with symptoms, new patient

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9
Q

Chief Complaint

A

SUBJECTIVE statement made by patient describing most significant symptom
Ask patient questions

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10
Q

Vitals

A

pulse, respirations, blood pressure, pain assessment`

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11
Q

oral temp

A

orally - electronic or digital
98.6

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12
Q

Aurally (ear) temp

A

tympanic
98.6

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13
Q

axillary temp

A

least accurate
under armpit
97.6

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14
Q

rectal temp

A

most accurate
electronic or digital
99.6

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15
Q

Pulse

A

normal 60-100
take at radial for 30 x 3
if irregular take for one minute

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16
Q

tachycardia

A

pulse greater than 100

17
Q

bradycardia

A

pulse lower than 60

18
Q

pulse - check for

A

rhythm and volume

19
Q

apical pulse

A

used for infants using a stethescope

20
Q

apex

A

5th intercoastal space between ribs on left side and sternum