Term
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Definition
1. Admission Note
2. New Patient note
3. "Physical Note"
4. Includes ALL segments of Hx |
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Term
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Definition
1. Progress Note
2. Acute Visit Note
3. Follow up Note
4. Contains SELECTED Hx and physical components that are relevant to CC. |
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Term
T or F
Comprehensive Write Ups must be in chronological order |
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Definition
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Term
T or F
In a comprehensive write up, vital signs may be excluded on a patient because it is irrelevant to check because of a particular chief complaint. |
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Definition
False
Vital signs should be included on EVERY patient |
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Term
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Definition
Problem list definition:
All of the patient's acute and chronic problems
List them in decreasing order of severity. |
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Term
| What goes in the Assessment/Plan category of a comprehensive write up? |
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Definition
Assessment: Possible diagnoses and your reason for those diagnoses
Plan: Any further diagnostic tests; how you're going to treat the problem |
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Term
Focused Write ups:
Acute Visit Note
What is a "S.O.A.P." note?
High Yield Question! |
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Definition
S: Subjective (Results from communication)
O: Objective (Results from physical exam/diagnostic data
A: Assessment (Possible diagnoses)
P: Plan (further diagnostic tests; how you will treat problem) |
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