Ch 2 - Introduction To Health Records Flashcards
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what does S.O.A.P stand for?
Subjective, Objective, Assesment, Plan
subjective
what a patient is feeling - experiences and personal description of the problem (how long a problem is happening, severity, etc)
objective
data - physical exam, labs, and imaging
assessment
logical analysis - identification or diagnosis of problem or a list of potential diagnoses (differential diagnosis)
plan
course of action consistent with assessment - treatment or procedure or further data collection
acute
just started, or is a sharp, severe symptom
chronic
going on for a while now
exacerbation
is getting worse
abrupt
all of a sudden
febrile
to have a fever
afebrile
to not have a fever
malaise
not feeling well
progressive
more and more each day
symptom
something a patient feels
noncontributory
not related to this specific problem
lethargic
decrease in level of consciousness, very ill
genetic/hereditary
runs in the family
chief complain
main reason for the patients visit
history of present illness
story of the patients problem
review of symptoms
description of individual body systems in order to discover any symptoms not directly related to the main problem
past medical history
other significant past illness (ex high blood pressure, asthma, diabetes)
past surgical history
past surgeries
family history
any significant illness that run in the family
social history
record of habits like smoking, drinking, drug abuse, and sexual practices
discharge summary note
details when and why a patient was admitted, what happened during stay, what kind of follow up needs to happen
discharge summary
differs from the SOAP method - it starts with the diagnoses
emergency department note
will generally include an “ED course” - what happened to the patient during ED stay (includes mix of any testes, and assessment and plans)
operative note
similar to discharge summary - will include diagnosis at the top
progess note/daily hospital note
usually assessment and plan sections are put together
radiology note
explains reason for ordering radiologic image, how the image was performed, what was seen, and reviewing radiologist assessment, sometimes a recommendation (usually another image or to repeat the same image at a different time)
pathology note
mirrors the radiology note (shows the reason for the test and what was seen in detail)
perscription
doesn’t use SOAP method at all - has its own structure
1) name and strength of medicine
2) Sig: patient instructions
3) Dispense: how much medicine to give to patient
4) Refils: how many are available
5) Signature
CCU
coronary care unit
ECU
emergency care unit
ER
emergency room
ED
emergency dept
ICU
intensive care unit
PICU
pediatric intensive care unit
NICU
neonatal intensive care unit
SICU
surgical intensive care unit
PACU
post-anesthesia care unit
L&D
labor and delivery
OR
operating room
post-op
after surgery
pre-op
before surgery
