SOAP Flashcards
Problem list contains:
objective findings that include:
Impairments
Activity Limitations
Participation Restriction
The problem list can contain findings that may be
Active or Inactive
The findings in the problem list can be marked as
Controlled
Resolved
Unresolved
Daily Progress notes are written every
every 6 days
Advantages of POMR
Organized and structured medical info
Includes a comprehensive list of pt’s problems
Discusses each pt problem
Provide separate care for each problem
Provide specific plan for each prolem
Chronological sequence of interventions
Disadvantages of POMR
Separates each problem of the pt
Time consuming
What are the types of notes
Initial Evaluation/Initial Note
Progress note
Discharge note
Components of patient management process
Examination
Evaluation
Diagnosis
Prognosis
POC
ABCs of writing a medical record
Accuracy
Brevity
Clarity
Rules for using hyphen
Should be avoided at all times; must be used only in recording ROMs
Rules for using semi-colon
Substitute for the word “states”
Rules for using colon
Substitute for “is”
The process of signing patient care notes
authentication
How to correct errors?
strikethrough the error using a single line then write last name + name initials, date, and signature above
Two important components of writing verbal orders
Time/Date/Order
v.o Physician’s name/Therapist’s name, (PT/OT)
