AHS 100 Chapter Notes - Chapter 2: Electronic Health Record, Soap Note, Medical Record
Chapter 2: Introduction to Health Records
●Information found in paper chart or an electronic health record
(EHR), serve as a roadmap of the patients health history detailing
previous illness, continuing medical problems, history of family
illness, and any current medications. It provides a clearer picture of
the best route to take in future treatment for the patient.
●Medical records are an indispensable component of medicine so it
is prudent to be well acquainted with their general layout.
2.1 The SOAP Method
●Patient visits typically revolved around addressing a problem.
Providers employ a logical approach to solving these problems, it is
presented as SOAP. It stands are Subjective, Objective, Assessment,
and Plan. By collecting data and using deductive reasoning, a
healthcare provider can make the most accurate assessment of the
patient’s problem
●S: the first part of the note is the subjective part. It is subject to how
a patient experiences and personally describes their problem as well
as personal and family medical history. The problem in the patient's
own words. This data includes the timeline of the problem, the
quality of the problem, and any exacerbating or relieving factors for
that problem.
●O: next is the collection of objective data. This contains the patients
physical exam, any lab findings, and imaging studies performed at
the visit.
●A: upong gathering all the patient info, the health care provider
concludes a logical analysis known as the assessment. It could be a
diagnosis, and identification of a problem, or a list of possibilities for
the diagnosis.
●P: the provider formulates a plan or a course of action aligning with
her or her assessment. It could be a treatment with medicine or
procedure. Also it could consist of collecting further data to help
arrive at a more accurate diagnosis.
●The process of collecting the SOAP information is repeated in every
health care visit across all medicine practices.
2.2 Types of Health Records
●Routinely medical records are scoured to find specific info such as
“what meds did the cardiologist prescribe for the patient?”, “when is
the patient supposed to follow up?”, and “what did the patient have?”
Document Summary
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