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Understanding SOAP Format in Medical Records: Subjective, Objective, Assessment, and Plan, Quizzes of Introduction to Business Management

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.

Typology: Quizzes

2010/2011

Uploaded on 04/27/2011

zanibchavan
zanibchavan 🇺🇸

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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
pf3
pf4

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SOAP; METHOD OR VARIATIONS

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

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

permanent medical record;

These notes are a part of the patients permanent medical record;

medical records are vital in patient care although medical records

are used mainly to assist the physician with care of the patient,

they can be reviewed by attorneys, other physicians, insurance

companies, or the court. It is essential that they be neat, accurate,

and complete (Chapter 11) Introduction

TERM 7

Accurate means

DEFINITION 7

Accurate means that they are transcribed as dictated, and

complete requires that they be dated and signed or initialed by the

dictator. It is hard to insist that the physician sign or initial the

records, but making it easier to do so: for example, by typing a

line at the end of each chart entry for the signature or initials.

(Chapter 11) Introduction

TERM 8

Persons dictating and those transcribing or

editing records must follow established

guidline

DEFINITION 8

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

generally found in these records and help you

set it up in a logical manner

DEFINITION 9

1.The records must be complete and legible.2.Each patient

encounter should include the following documentation:DateReason

for the encounterHistory, physical examination, prior diagnostic

test resultsDiagnosis (assessment, impression)Plan for careName

of the observer3.Rationale for ordering diagnosis or other services

should be documented or inferred.4.Health risk factors should be

identified.5.Progress, response to treatment, changes in

treatment, and revision of diagnosis should be documented.

TERM 10

chief complaint (CC);

DEFINITION 10

The CC describes the symptom, problem, or condition that is

the reason for the encounter and must be clearly describes

in the record

the O (objective

portion taking the place of the physical examination (PX OR

PE);

TERM 17

the A ( assessment)

DEFINITION 17

portion taking the place of the diagnosis portion of the

examination;

TERM 18

the P ( Plan)

DEFINITION 18

portion taking the place of the outlined future treatment