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6 Cards in this Set
- Front
- Back
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SUBJECTIVE
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Info about pt. medical hx;
Symptoms or complaints that caused pt. to seek medical attention; factors that produced symptoms; pt.'s functional & lifestyle needs; pt.'s goals & expectations of medical care |
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SUBJECTIVE
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Providesevidence of tx. effectiveness or progress toward goals.
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OBJECTIVE
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Info that is reproducible and readily demonstrable. info is gathered using data-collecting methods such as measurements, tests & observations.
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OBJECTIVE
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Signs of the pt.'s condition.
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ASSESSMENT
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Clinical judgment & functional outcomes & goals based S & O sections. Summarizes S & O and reports progress toward goals.
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PLAN
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What will happen next.
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