Chapter 2
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| SOAP | S= subjective - what the patient says O=objective - what tests reveal A= assessment - analysis of the subjective and objective info P=plan - course of action
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| chief complaint | main reason for the patient's visit
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| review of systems | description of individual body systems in order to discover any symptoms not directly related to the main problem
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| social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that impact health
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| A&O | alert and oriented
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| PERRLA | pupils are equal and reactive to light and
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| NAD | no acute distress
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| CTA | clear to auscultation
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| RRR | regular rate and rhythm
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| NOS | not otherwise specified
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