Sherpath Ch 26 Documentation and Informatics

Question 1

The EHR contains

Answer 1

specific information about the patient’s medical history, treatment plans, diagnostic test results, current and previous health diagnoses, allergies, and medications. It is an individualized “map” of the patient to plan appropriate care.

Question 2

SOAP

Answer 2

subjective (S), objective (O), assessment (A), and plan (P)
-sometimes expanded to a SOAPIE note, which includes the actual interventions (I) and an evaluation (E) of intervention outcomes.