Ch 2 - Introduction To Health Records

Question 1

what does S.O.A.P stand for?

Answer 1

Subjective, Objective, Assesment, Plan

Question 2

subjective

Answer 2

what a patient is feeling - experiences and personal description of the problem (how long a problem is happening, severity, etc)

Question 3

objective

Answer 3

data - physical exam, labs, and imaging

Question 4

assessment

Answer 4

logical analysis - identification or diagnosis of problem or a list of potential diagnoses (differential diagnosis)

Question 5

plan

Answer 5

course of action consistent with assessment - treatment or procedure or further data collection

Question 6

acute

Answer 6

just started, or is a sharp, severe symptom

Question 7

chronic

Answer 7

going on for a while now

Question 8

exacerbation

Answer 8

is getting worse

Question 9

abrupt

Answer 9

all of a sudden

Question 10

febrile

Answer 10

to have a fever

Question 11

afebrile

Answer 11

to not have a fever

Question 12

malaise

Answer 12

not feeling well

Question 13

progressive

Answer 13

more and more each day

Question 14

symptom

Answer 14

something a patient feels

Question 15

noncontributory

Answer 15

not related to this specific problem

Question 16

lethargic

Answer 16

decrease in level of consciousness, very ill

Question 17

genetic/hereditary

Answer 17

runs in the family

Question 18

chief complain

Answer 18

main reason for the patients visit

Question 19

history of present illness

Answer 19

story of the patients problem

Question 20

review of symptoms

Answer 20

description of individual body systems in order to discover any symptoms not directly related to the main problem

Question 21

past medical history

Answer 21

other significant past illness (ex high blood pressure, asthma, diabetes)

Question 22

past surgical history

Answer 22

past surgeries

Question 23

family history

Answer 23

any significant illness that run in the family

Question 24

social history

Answer 24

record of habits like smoking, drinking, drug abuse, and sexual practices

Question 25

discharge summary note

Answer 25

details when and why a patient was admitted, what happened during stay, what kind of follow up needs to happen

Question 26

discharge summary

Answer 26

differs from the SOAP method - it starts with the diagnoses

Question 27

emergency department note

Answer 27

will generally include an “ED course” - what happened to the patient during ED stay (includes mix of any testes, and assessment and plans)

Question 28

operative note

Answer 28

similar to discharge summary - will include diagnosis at the top

Question 29

progess note/daily hospital note

Answer 29

usually assessment and plan sections are put together

Question 30

radiology note

Answer 30

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)

Question 31

pathology note

Answer 31

mirrors the radiology note (shows the reason for the test and what was seen in detail)

Question 32

perscription

Answer 32

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

Question 33

CCU

Answer 33

coronary care unit

Question 34

ECU

Answer 34

emergency care unit

Question 35

ER

Answer 35

emergency room

Question 36

ED

Answer 36

emergency dept

Question 37

ICU

Answer 37

intensive care unit

Question 38

PICU

Answer 38

pediatric intensive care unit

Question 39

NICU

Answer 39

neonatal intensive care unit

Question 40

SICU

Answer 40

surgical intensive care unit

Question 41

PACU

Answer 41

post-anesthesia care unit

Question 42

L&D

Answer 42

labor and delivery

Question 43

OR

Answer 43

operating room

Question 44

post-op

Answer 44

after surgery

Question 45

pre-op

Answer 45

before surgery