Chapter 2 Flashcards
SOAP
Subjective, Objective, Assessment, Plan
Subjective
What the patient describes
Objective
What the tests reveal
Assessment
The analysis of the subjective and objective information; a diagnosis
Plan
The course of action for the patient. Ex: Medication, physical therapy, surgery, etc.
Physician
A skilled health professional who attended and graduated medical school
Pediatrician
A physician with a special training in caring for children
Surgeon
A physician qualified to treat patients surgically
Anesthesiologist
A physician with special training in pain sedation and pain control
Physician assistant
A mid level health care provider who works under the license of a supervising physician
Nurse practitioner
A nurse with postgraduate training that serves as a mid level health care provider
Emergency medical technician (EMT)
Specially trained in the emergency care of a patient before and/or during transport to a medical facility
Speech therapist
Specially trained in evaluating and treating problems with speech and/or swallowing
Occupational therapist
Specially trained in evaluating and treating problems with performing daily activities at home, school, or work.
Physical therapist
Specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury
Respiratory therapist
Specially trained in treating patient’s respiratory issues under the guidance of a health care provider
Dietician
Specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan
Licensed practical nurse (LPN)
Trained and certified to provide basic care to a patient
Registered nurse (RN)
An advanced level nurse who has completed and associates or bachelors degree
Medical assistant
Trained to carry out basic administrative and clinical tasks under the guidance of a health care provider
Pathologist
A physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
Medical laboratory technician
Trained in performing laboratory testing on bodily fluids
Phlebotomist
Trained int he removal of blood from the body for diagnostic or therapeutic purposes
Radiologist
A physician specially trained in evaluating images of the body to diagnose illness or injury
Radiology technician
Trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
Ultrasonographer
Trained in performing ultrasound imaging on a patient
Pharmacist
Trained and licensed in preparing and dispensing medicine
Pharmacy technician
Trained to assist a pharmacist with pharmacy-related tasks
Patient service coordinator
Handles administrative tasks and coordinates patient care
Medical transcriptionist
Trained in converting the voice-recorded dictations of health care providers into text format
Chief complain
The main reason for the patient’s visit
History of present illness
The story of the patient’s problem
Review of systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem
Past medical history
Other significant past illnesses
Past surgical history
Any of the patient’s past surgeries
Family history
Any significant illnesses that run in the patient’s family
