SOAP Note: Subjective, Objective, Assessment, and Plan
Classified in Medicine & Health
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SOAP Note: Subjective
This section usually includes the patient's chief complaint, or reason why they came to the physician.
Objective
Documents objective, repeatable, and traceable facts about the patient's status.
Assessment
The physician's medical diagnoses for the medical visit on the given date of a note written.
Plan
This describes what the healthcare provider will do to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc.
Attending Physicians
Is the individual who has final responsibility, legal and otherwise, for patient healthcare.
Office visit: used in SpringCharts to designate the GUI.
Metric units: system of weights and measures, based on the metric system.
Imperial units: system of weights and measures conforms to the standards legally established in Great Britain.
Primary insurance: long-term healthcare can be expensive, individuals and families have the option to purchase health insurance that covers a portion of the incurred medical expenses.
Secondary insurance: pays for some of the patient's medical expenses.
End-to-end solution: software industry term suggests that the vendor of an application program can provide all the hardware and software.
User preferences: are choices a user makes in software programs to preset elements.
Graphical user interface (GUI): a software program screen that can display icons, subwindows, and text fields.
Routing slip: charge ticket or super bill contains the healthcare codes, description, and charges relevant to a patient's visit.
SOAP note is a convenient format for healthcare providers to document a patient's healthcare evaluation.
Review of systems: a structured technique used by providers to gather healthcare history covering the organ system from a patient.
What are 2 places where a patient's facesheet can be edited?