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