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9 Cards in this Set

  • Front
  • Back
what are the characteristics of good patient documentation?
-comprehensive
-clear
-complete
-descriptive
-descrete
-legible
-accurate
-organized
-legible
what are some techniques to minimize liability?
-only use approved abbreviations
-never alter a patient record
-ammend errors in the appropriate manner
what does the acronym SOAP stand for?
-Subjective
-Objective
-Assessment
-Plan
subjective
-information obtained directly from the patient or the family
objective
-info from your own observations
assessment
-describes your impressions of the current medical problems
-includes differential diagnosis and reasoning behind your diagnosis
plan
-plan for treatment and follow up
how should you document a chief complaint?
-chief complaint is the reason the person came to your office
-use qoutations
what are the 7 attributes of a symptom?
-location
-quality
-severity
-timing
-setting
-remmiting/exacerbating factors
-associated symptoms