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Definitions and explanations of various terms related to the soap format used in medical record keeping. The soap format includes subjective (s), objective (o), assessment (a), and plan (p) sections. The subjective section covers the patient's perspective, objective section deals with physical findings, assessment section includes the diagnosis, and plan section outlines the treatment. The document also covers non-urgent, urgent, and emergency care, as well as chart notes and their importance.
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S; this signifies subjective, subjective means 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 refers 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 according 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, medications, referral to another practitioner, treatment, management and so forth. TERM 2
Identify the patient by name and health record number when applicable on every page in the records or computerized record screen, every form, and every computerized printout. Make entries as soon as possible after an event or observation is made.(Entries are never made in advance.)Include a complete date and time on every entry.Use blank ink for written entries. You must ensure that these are legible.Use specific language; avoid vague or generalized language.Record objective facts, not what is presumedDocument what can be seen, heard, touched, and/or smelled.Describe signs or symptomsUse quotation marks when quoting the patient.Document the patients response to care.Use only abbreviation approved by the organization. TERM 9