HLTH 2300 Lecture 2: Chapter 2 - Introduction to Health Records
Document Summary
Soap: an acronym that stands for the four general parts of a medical note. Subject to how a patient experiences and personally describes his/her problem as well as personal and family medical histories including the duration of the problem, quality of the problem, and exacerbating/relieving factors for that problem. Patient"s physical exam, laboratory findings, and imaging studies. Patient"s physical exam, laboratory findings, and imaging studies performed at the visit. Health care provider formulates a logical analysis diagnosis, identification of a problem, list of possibilities (differential diagnosis) Course of action consistent with his/her assessment treatment with medicine or a procedure or collecting further data. Commonly used medical words not necessarily based on ancient languages. You will use them so often that they will become part of your normal vocabulary. It just started recently or is a sharp, severe symptom. A decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick.
