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