Chapter 2 (EMR) Flashcards
Introduction to Health Records
The SOAP Method
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective
The “S”OAP Method
What the patient says.
Problems that the patient states they have, then translated into medical terms:
- main reason for health visit
- description of the problem
- timing of the problem
- previous medical history
- family medical history
- current medication and allergies
Objective
The S”O”AP Method
What the tests reveal.
This is the data collected by the health care provider.
This information also includes data obtained from lab tests or special images of the patient’s body,
Assessment
The SO”A”P Method
The analysis of the subjective and objective information; performed by the health care provider.
This is the combination of the subjective and objective information.
This information leads to a conclusion about the problem known as the diagnosis.
Plan
The SOA”P” Method
The course of action for the patient.
The plan is what the provider recommends to the patient regarding their current health status.
This can include medication, surgery, and/or further tests, among other options.
cranial
KRAY-nee-al
toward the top
proximal
PRAWK-sih-mal
closer in to the center
proximal and approximate come from the same word and mean close
distal
DIS-tal
farther away from the center
distal and distant come from the same word and mean far
caudal
KAWD-al
toward the bottom
from Latin, for tail
inferior
in-FEER-ee-or
below
superior
soo-PEE-ree-or
above
supine
SOO-pain
lying down on back
prone
PROHN
lying down on belly
contralateral
KON-trah-LAT-eh-ral
opposite side
lateral
LAT-er-al
out to the side
think of a quaterback lateraling a football to a running back
medial
MEED-ee-al
toward the middle
like to the median of a highway
ventral/antral/anterior
VEN-tral / AN-tral / an-TEER-ee-or
the front
the word ventral means “stomach”
dorsal/posterior
DOR-sal / pos-TEE-ree-or
the back
a dorsal fin on a shark is on its back
ipsilateral
IP-sih-LAT-eh-ral
same side
unilateral
YOO-nih-LAT-er-al
one side
bilateral
bai-LAT-eh-ral
both sides
dorsum
DOR-sum
the top of the hand or foot
palmar
PAL-mar
the palm of the hand
plantar
PLANT-ar
the sole of the foot