MEDICAL NOTE Flashcards
WHAT IS A MEDICAL NOTE?
LEGAL DOCUMENTATION EMPLOYED BY HEALTH CARE PROVIDERS (NURSES, NUTRICIAN, PHYSICIAN) TO DESCRIBE PATIENTS HEALTH CONDITION
THE MEDICAL NOTE ENSURES…
SYSTEMATIC DOCUMENTATION OF MEDICAL HISTORY, DX, TREATMENT AND CARE
WHAT IS THE DIFFERENCE BETWEEN MEDICAL HISTORY AND MEDICAL NOTE?
IT IS MORE FOCUSED
WHAT IS OTHER NAME FOR MEDICAL NOTE?
SOAP
WHAT MEANS S IN “SOAP”?
SUBJECTIVE
WHAT MEANS O IN “SOAP”?
OBJECTIVE
WHAT MEANS A IN “SOAP”
ASSESMENT
WHAT MEANS P IN “SOAP”?
PLAN
What is the ideal medical note?
that records every medically event that has happened to patient since birth. As diseases, inmunizations, development of new allergies, follow-ups, rehab, radiologic procedures/studies, treatment.
A MEDICAL NOTE LENGTH …
DEPENDS ON THE CIRCUMSTANCES. SURGICAL NOTE MAY BE BRIEFER THAN A MEDICAL FOLLOW UP
WHAT IS SUBJECTIVE PART?
DESCRIPTIVE STATEMENT OF PATIENTS STATE OF HEALTH.
IT SAYS SYMPTOMS– NOT MEASURABLE IT CAN BE ASSOCIATED SYMPTOMS AS WELL
IF RELEVANT ADD MEDICAL HISTORY BUT IT HAS TO BE FOCUSED ON CHIEF COMPLAINT
WHAT INCLUDES THE MEDICAL NOTE AT THE BEGINNING?
DATE AND TIME OF ELABORATION
ID AND CHIEF COMPLAINT
WHAT IS THE OBJECTIVE PART?
THIS IS OBSERVABLE MEASURABLE AND QUANTIFICABLE DATA
PHYSICAL EXAMINATION
LAB WORK IF RELATED
DESCRIPTION OF FINDINGS
WHAT IS ASSESMENT?
IS THE MEDICAL ANALYSIS, SCIENTIFIC AND CLINICAL JUSTIFICATION OF THE PATIENTS CONDITION TRANSLATED INTO: 1 PRIMARY DX AND 2 SECONDARY DX
WHAT MEANS PLAN?
IT COULD BE A INMEDIATE PLAN, MIDTERM PLAN, LONG TERM PLAN.
DX- LABWORK/IMAGES
RX- PRESCRIPTION (DRUG NAME, DOSAGE, FREQUENCY, ADMINISTRATION, WITH OR WITHOUT FOOD, FASTIG, SCHEDULED AT CERTAIN HOUR, DURATION)
EX- MEDICAL EDUCATION- BEHAVIOR AND FOLLOWUP IN … DISCHARGE, REFFERENCE TO, SECOND OPINION
