SOAP- 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 health care 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 measure 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 patients 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 is 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 patients visit.
SOAP- note is a convenient format for healthcare providers to document a patients healthcare evaluation.
review of systems: is a structured technique used by providers to gather healthcare history covering the organ system from a patient.
what are 2 places where patients facesheet can be edited?