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10 Cards in this Set

  • Front
  • Back

Subjective

It is subject to how a patient experiences and personally describes his or her problem as well as personal and family medical histories

Objective

Objective data comprise the patient's physical exam any laboratory findings and imaging studies performed at the visit

Assessment

Gathering all the pertinent information the healthcare provider formulates a logical analysis

PLAN

The provider formulate a plan or a course of action consistent with his or her assessment the plan could be treatment with medicine or a procedure

Transverse plane

Divides the body from top to bottom

Coronal plane

Divides the body into slices from front to back

Sagittal plane

Divides the body in slices right to

PO

Per Os by mouth

Wnl

Within normal limits

Nos

Not otherwise specified