Medical Terminology - Chapter 2

What is the SOAP method?

subjective, objective, assessment, plan

What is the "S" is SOAP?

subjective - what the patient is feeling in their own words

What is the "O" is SOAP?

objective - data collected from the patients physical exam, laboratory findings, and imaging studies

What is the "A" in SOAP?

a diagnosis, identification of a problem, or a list of possibilities for the diagnosis

What is the "P" in SOAP?

course of action consistent with the assessment

Chief Complaint

the main reason for the patients visit

History of present illness

the story of the patient's problem

review of systems

description of individual body systems in order to discover any symptoms not directly related to the main problem

past medical history

other significant past illnesses

past surgical history

any of the patient's past surgeries

family history

any significant illnesses that run in the patients family

social history

a record of habits

clinic note

when a healthcare professional sees a patient in an office setting

consult note

a note from a visit to a specialist or consultant

emergency department note

patients seen in emergency departments or urgent care clinics

admission summary

summary upon admittance to the hospital after patient provides a medical history and receives a physical exam

discharge summary

a note that details when and why a patient was admitted

operative report

a report that documents in detail the procedure that was performed, the events that transpired, and the patient's outcome from the surgery

daily hospital note/progress note

a health care professional must see the patient and document the visit every day the patient is in the hospital

radiology report

a report that explains the reason for ordering a radiologic image, how the image was performed, and what was seen on the image, and the reviewing radiologist's assessment

pathology report

mentions the reason for the study, what was seen in detail, and the assessment

presription

the plan

What is the first line of a prescription for?

name and strength of the medicine

What is the second line of a prescription for?

"sig" - contains the patient's instructions

What is the third line of a prescription for?

dispense - tells the pharmacist how much medicine to give the patient

What is the fourth line of a prescription for?

how many refills are available for the prescription

What is the fifth (last) line of a precription for?

health care provider's signature