History Taking
This format organizes patient information into four specific sections to ensure comprehensive and structured clinical documentation.
What is the SOAP note format?
This is the first set of measurements taken during a physical exam, including temperature, pulse, respiratory rate, and blood pressure.
What are vital signs?
This instrument is used to auscultate heart, lung, and bowel sounds.
What is a stethoscope?
This act protects the privacy and security of individuals' medical records and other health information.
What is HIPAA (Health Insurance Portability and Accountability Act)?
This abbreviation stands for "electrocardiogram."
What is EKG or ECG?
This is the primary reason a patient seeks medical care, often stated in their own words.
What is the chief complaint?
This technique uses a stethoscope to listen to internal body sounds, such as heart, lung, and bowel sounds.
What is auscultation?
This instrument is used to test deep tendon reflexes, such as the knee-jerk reflex.
What is a reflex hammer?
Every medical entry should include this information to provide a clear timeline of patient care.
What is date and time?
This abbreviation means "nothing by mouth."
What is NPO?
This history section covers a patient's lifestyle factors, including smoking, alcohol use, occupation, and living situation.
What is the social history?
This aspect of the physical exam assesses the way a patient walks, looking for abnormalities in movement and balance.
What is gait?
This instrument helps in diagnosing ear infections, wax buildup, and other ear-related issues.
What is an otoscope?
This must be verified and included on every page of the patient's medical record to avoid mix-ups.
What is patient identification?
This abbreviation stands for "as needed."
What is PRN?
This part of the SOAP note contains measurable and observable data, such as vital signs, physical exam findings, and results from diagnostic tests.
What is the objective section?
This part of the neurological exam assesses the body's automatic response to stimuli, such as the knee-jerk reaction.
What are reflexes?
This instrument allows for the visualization of the retina, optic disc, and blood vessels within the eye.
What is the function of an ophthalmoscope?
This act requires hospitals to provide emergency medical treatment to anyone needing it, regardless of citizenship, legal status, or ability to pay.
What is EMTALA (Emergency Medical Treatment and Labor Act)?
This abbreviation stands for "twice a day."
What is BID?
This systematic questioning helps to identify any symptoms the patient might have overlooked, covering various body systems.
What is the review of systems?
This technique involves tapping on the body surface to determine the underlying structure’s density.
What is percussion?
This instrument is used to assess hearing and vibration sense.
What is a tuning fork?
Documentation of this is essential before performing any procedures or treatments.
What is informed consent?
This abbreviation indicates "before meals."
What is AC?