Chapter 2 Other Flashcards
This part of the soap method includes the direction of the problem, the quality of the problem, and any exacerbating or relieving factors for that problem. It is the problem in the patient’s own words.
Subjective
The part of the soap method that consists of the patient’s physical exam, any laboratory findings, and imaging studies performed at the visit.
Objective
This part of the soap method consists of gathering all the pertinent information and formulating a logical analysis. It could have a diagnosis.
Assessment
The part of the soap method that consists of a course of action consistent with the assessment. It could be a treatment with medicine or a procedure. Also consist of collecting further data to help arrive at a more accurate diagnosis.
Plan
Anytime a healthcare professional sees a patient in an office setting, he or she must document the visit in a
Clinic note
A note from my visit to a specialist or consultant.
Consult note
A note from the emergency department and urgent care clinics
Emergency department note
Upon admittance to the hospital, this detailed paper is usually thorough notes that are very heavy on the subjective and objective parts, because the idea of the this is to assemble all the facts in one place to help direct the entire hospital course.
Admission summary
A note with details on when and why a patient was admitted. It includes how the patient felt when admitted, what happened during the patients stay in the hospital, and what kind of follow up the patient will have.
Discharge summary
After each surgery, the surgeon completes this that document in detail the procedure that was performed, the events that transpired during the surgery, and the patient outcome from the surgery.
Operative report
Every day that a patient is seen in the hospital, a healthcare professional must see him or her and document the visit. Usually, the subject of part of these daily hospital notes focuses on how the patient’s condition has changed since the previous note. Often, the notes assessment and plan sections will be put together, as with an admission note
Daily hospital note/progress note
This note explains the reason for ordering the radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist assessment. Sometimes the no provides a recommendation as well.
Radiology report
This note mirrors the same style as the radiology note. This not mentions the reason for the study, but was seen in detail, and the assessment
Pathology report
Which type of note does not follow the soap note format
Prescription
The first line of the prescription is
For the name and strength of the medicine
The second line of the prescription is
Marked Sig, contains the patients instructions
The third line of her prescription is
Usually marked dispense, tells the pharmacist how much medicine to give the patient
The fourth line of a prescription
Mentions how many refills are available for the prescription
The prescription forms last line is for
The healthcare provider signature.
A prescription know usually includes a box the healthcare provider can check to indicate whether they prescribe medication must be
A brand-name instead of generic
Which part of the soap method includes the main reason for the health visit, the description of his or her problem, the timing of the problem, previous medical problems or surgeries, family health problems that might relate, current medications and allergies
Subjective
Which part of the soap method contains what the provider notices about the patient when he or she examines the patient closely it states how the patient looks, sounds, feels, smells. It also includes any extra data obtained by tests done in a laboratory or by special images of the patient’s body
Objective
Which part of this so method is where all the information is put together to reach a conclusion on the nature of the problem. This is where you would find the diagnosis.
Assessment
A healthcare provider may list of most likely causes, called a – – –
Differential diagnosis
Which part of the soap method lays out what the provider recommends to do about the patient’s current health status. It may include medicine or home remedies, help from another health provider, surgery, or even waiting to see if the problem will improve on his own. Sometimes this is for more data collection to be done in the future to help figure out the true cause of the problem
Plan
