Where in the SOAP
Currently taking acetaminophen 2x a day for pain
Subjective
visual tools that help track certain information in patient’s medical records like a pre-set return to play protocol.
Flow Chart
18 inches or closer
Intimate space
Neck Pulse is also called the _____ pulse
Carotid Pulse
Cyanosis of the hands
Objective
Documenting the patients exact words rather than writing a summary
Client's Word
where verbal & non verbal messages do not match.
Kinesics Slip
Continuous, low-pitched sounds that are best heard during exhalation
Gurgling/Rhonchi
MRI to that confirm diagnoses during evaluation
Plan
Organize in ABC order
R. Singleton, Roberta Singleton, Lisa-Marie Taylor, Elizabeth Taylor, Terry McDonald
Terry McDonald, R. Singleton, Roberta Singleton, Elizabeth Taylor, Lisa-Marie Taylor
the study of non-verbal communication.
Kinesics
Coarse sounds that can be brief and discontinuous, or popping and high-pitched
Crackles/Rales
Contusion to the lateral aspect of the knee
Subjective
Noting that the patient's pain level and ankle ROM has increased in 1 week compared to the previous week.
Progress Note
Public Space
12 ft or more
Allergic to the cold
Raynaud's
Neuromuscular inflammation of the spinal cord
Assessment
POMR means
Problem-Oriented Medical Record Charting
Patient said their pain level is a 10/10 and you restate their statement.
Paraphrasing
PEARL
Pupils, Equal, Round, Reactive & Accommodations