BASIC MEDICAL DOCUMENTATION Flashcards
BASIC MEDICAL DOCUMENTATION (5)
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
SOAP DOCUMENTATION
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
SUBJECTIVE (SOAP)
CHIEF COMPLAINT
OBJECTIVE(SOAP)
MEASUREABLE DATA - VITALS, LABS, MEASUREMENTS
ASSESSMENT (SOAP)
MEDICAL DIAGNOSIS
PLAN (SOAP)
FOR TREATMENT
PATIENT INTERVIEW
FIRST STEP IN EXAM PROCESS
ESTABLISHES A RELATIONSHIP
EXCHANGE OF INFO
reason for appointment
establish - “why are you here today?”
routine checkup, follow up, established pt with symptoms, new patient
Chief Complaint
SUBJECTIVE statement made by patient describing most significant symptom
Ask patient questions
Vitals
pulse, respirations, blood pressure, pain assessment`
oral temp
orally - electronic or digital
98.6
Aurally (ear) temp
tympanic
98.6
axillary temp
least accurate
under armpit
97.6
rectal temp
most accurate
electronic or digital
99.6
Pulse
normal 60-100
take at radial for 30 x 3
if irregular take for one minute