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11 Cards in this Set
- Front
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The SOAP Method the soap method reflects the thought process of health professionals in general. providers employ a logical approach to solving these problems. in its most rudimentary form the pattern is presented as what is known as a SOAP note. it is an acronym that stands for the general parts of the medical note. |
this parts are what are called Subjective, objective, assessment and plan. these four stems makes up what we called the soap method. |
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Subjective: it is the problem in the patients own words, it include the duration of the problem, the quality of the problem, any exacerbating or relieving factors for that problem. Objective: it comprises of the patient physical exam, any laboratory findings and imaging studies performed at the visit. it also involves data collecting. |
Assessment: it is a logical analysis, it could be diagnosis, an identification of a problem or a list of possibilities for the diagnosis which is known as differential diagnosis. Plan: is a course of action consistent with his or her assessment. it could be a treatment with medicine or a procedure. |
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The General Subjective Terms Acute: it just started recently or is a sharp severe symptom Chronic: it has been going on for a while now Exacerbation: it is getting worse. Abrupt: all of a sudden. Febrile: to have a fever. Afebrile: to not have a fever. |
Malaise: not feeling well. Progressive: more and more each day. Symptom: something a patient feels. Noncontributory: not related to this specific problem. Lethargic: a decrease in level of consciousness in a medical record, this is generally an indication that the patients is really sick. Genetic/ hereditary: it runs in the family. |
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General Objective Terms Alert: able to answer questions, response, interactive. Oriented: been aware of who he or she is, where and current time, a patient who is aware of all these is oriented x3 Marked: it really stand out. Unremarkable: normal Auscultation: to listen Percussion: to hit something and listen to the resulting sound or feel for the resulting vibration. Palpation: to feel. |
General Assessment Terms Impression: another way to say assessment. Diagnosis: what the health care professional thinks the patient has. Differential diagnosis: a list of conditions the patient may have based on the symptoms exhibited and the results of the exam. Benign: safe Malignant: dangerous; a problem Degeneration: to be getting worse. |
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Etiology: the cause. Remission: to get better Idiopathic: no known specific cause Localized: stay in a certain part of the body. Mortality: the risk of dying Prognosis: the chance of getting better or worse. Occult: hidden. Recurrent: to have again. |
General Plan Term Disposition: what happen to the patient at the end of the visit. Discharge: to send home/ fluid coming out of part of the body Prophylaxis: preventive treatment. Palliative: treating the symptoms. Observation: watch, keep an eye on. Reassurance: to tell the patient the problem is not serious or dangerous. Supportive care: to treat the symptoms and make the patient feels better. Sterile: extremely clean. |
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Health Care Facility Abbreviation CCU-- coronary care unit ECU-- emergency care unit ER-- emergency room ED-- emergency department ICU-- intensive care unit PICU-- pediatric intesive care unit NICU-- neonatal intensive care unit SICU-- surgical itensive care unit PACU-- postanesthesia care unit L&D-- labor and delivery post-op-- after surgery pre-op-- before surgery |
Abbreviation Common on Health Records VS-- vital signs T-- teperature BP-- blood pressure HR-- heart rate RR-- respiratory rate Ht-- height Wt-- wieght BMI-- body mass index I/O-- intake and output Dx-- diagnosis DDx-- differential diagnosis Tx-- treatment RX-- prescriptiom H&P-- history and physical Hx-- history CC-- chief complaint HPI-- history of present illness |
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Abbreviation Common on Health Records ROS-- review of syetems PMHx-- past medical history FHx-- family history PE-- physical exam Pt--patient y/o-- years old h/o-- history of PCP--primary care provider f/u-- follow -up |
Summary of Health Record Notes clinic note consult note emergency note admission summary discharge summary operative report daily hospital note progress note radiology pathology prescription |
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Abbreviation used for Symptoms or Exam Findings RRR--regular rate and rhythm NAD--no acute distress WDWN-- well developed, well nourished A&O-- alert and oriented WHL-- within normal limits NOS-- not otherwise specified NEC-- not elsewhere classified |
Abbreviation used for Symptoms or Exam Findings SOB-- while it may mean something outside of medicine PERRLA-- pupils are equal, round and reactive to light and accommodation CTA-- clear to auscultation |
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Health Care Facility Abbreviation CCU-- coronary care unitE CU-- emergency care unit ER-- emergency room ED-- emergency department ICU-- intensive care unit PICU-- pediatric intesive care unit NICU-- neonatal intensive care unit SICU-- surgical itensive care unit PACU-- postanesthesia care unit L&D-- labor and delivery post-op-- after surgery |
Abbreviation Associated with Orders and Administering Medicine
PO-- per os. NPO-- nill per os. PR-- per rectum IM-- intramuscular SC-- subcutaneous IV-- intravenous CVL-- central venous line |
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Abbreviation Associated with Orders and Administering Medicine IM-- intramuscular SC-- subcutaneous IV-- intravenous CVL-- central venous line PICC-- peripherally inserted central catheter Sig-- instructions short for signa, from latin for label ad lib-- as desired |
Prescription Abbreviation
BID-- twice daily TID-- three times daily QD-- daily QID-- four times daily QHS-- at night AC-- before meal PC-- after meal prn-- as needed |
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BP blood pressure
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HR--Heart rate |
