TERM 1
SOAP; METHOD OR VARIATIONS
DEFINITION 1
S; this signifies subjective, subjective mean s from the patients point of view. This
is the reason the patient is seeking care. It is the main problem necessitating
care (also called chief complaint.).O: This ref ers to objective, or the physicians
point of view, and what is found on physical examination, x-ray film, or laboratory
work; the clinical evidence.A: This refers to assessment, or what the examiner
thinks may be or is wrong with the patient a ccording to the information gathered:
the diagnosis.P: This refers to plan, or what the physician plans to do or advises
the patient to do: laboratory tests, surgery, me dications, referral to another
practitioner, treatment, management and so forth.
TERM 2
Nonurgent care
DEFINITION 2
involves routine care that could have taken place in a
physicians office during office hours. Chart note, emergency
department visit
TERM 3
Urgent care
DEFINITION 3
involves care necessitating basic emergency services.
Problems include lacerations, acute flu symptoms, and mild
shortness of breath, broken bones, threatened abortion, and
rectal bleeding. Admission to the hospital is possible.
TERM 4
Emergency care
DEFINITION 4
involves care requiring immediate attention of the physician.
Problems include chest pain, stroke, and acute trauma, acute
shortness of sitating cardiopulmonary
TERM 5
also called chart notes or progress
notes
DEFINITION 5
Medical record notes (also called chart notes or progress
notes) are the formal or informal notes taken by the
physician when he or she meets with or examines a patient
in the office, clinic, acute care center, or emergency
department. (Chapter 11) Introduction
