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Intro to Health Records

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Term
Definition
show Subjective - These are the problems that the patient states they have. Those problems are then translated into medical terms.  
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SOAP Method [O]   show
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show Assessment - This is a combination of the subjective and objective information.  
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show Plan - The plan is what the provider recommends to the patient regarding their current health status. This can include medication, surgery, and/or further tests, among other options.  
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General Subjective Terms [Acute vs Chronic]   show
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show Progressive - More and more each day Exacerbation - It is getting worse  
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General Objective Terms [Alert vs Oriented]   show
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show Auscultation - To listen  
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General Assessment Terms [Differential Diagnosis]   show
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General Plan Terms [Palliative]   show
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