Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
11 Cards in this Set
- Front
- Back
|
purpose of reports
|
document pro opinon for pt complaints
summarize results of testing recommend further testing make recommendations for follow up |
|
|
basics of report writing
|
mostly intuitive (not step by step/transitioning to templates)
situational |
|
|
diagnostic reports: History
|
referral source
presenting complaint previous testing medical/hearing/HA history verifity info on case history |
|
|
diagnostic reports: results
|
reliability
testing procedures reporting all test resuts |
|
|
diagnostic reports: impressions/recommendations
|
summarize results
compare results to previous tests recommendations |
|
|
SOAP note (general)
|
condensed version of the report
may be only documentation of the enounter may have to limit info based on space |
|
|
S=
O= A= P= |
subjective
objective assessment plan |
|
|
S
|
relevant pt complaints
history medical/otologic data subjective observations (ex. pt poor historian) |
|
|
O
|
procedures preformed
results conditions present during testing provide understanding of approach taken for assessment of presenting complaint |
|
|
A
|
***most important
"impression secion" -should make sense is reviewed by someone else |
|
|
P
|
reccomendations
can be "next steps" for pt to follow document pt ed here |
