SOAP Notes & Medical History
This part of the SOAP note includes patient-reported information like pain, nausea, or fatigue.
What is the Subjective section?
This term describes the body’s ability to maintain stable internal conditions.
What is homeostasis?
Red blood cells are also known by this scientific name.
What are erythrocytes?
This hormone lowers blood glucose levels.
What is insulin?
HIPAA stands for this full federal law name.
What is the Health Insurance Portability and Accountability Act?
Swollen lymph nodes and a positive rapid test would be documented in this part of a SOAP note.
What is the Objective section?
The top number of a blood pressure reading represents this phase of the cardiac cycle.
What is systole?
These blood components are primarily responsible for clotting.
What are platelets (thrombocytes)?
This hormone raises blood glucose levels.
What is glucagon?
A nurse discusses a patient’s condition in a public elevator. This would be classified as what?
What is a HIPAA violation?
The doctor’s diagnosis belongs in this portion of the SOAP note.
What is the Assessment section?
A resting adult heart rate of 72 bpm would be considered within this range category.
What is normal?
This protein in red blood cells binds oxygen and gives blood its red color.
What is hemoglobin?
This type of feedback loop counteracts change to maintain stability.
What is a negative feedback loop?
Calling a patient directly to give lab results while verifying identity first would be considered what?
What is appropriate handling of protected health information?
Prescribing medication or recommending rest would be written in this section.
What is the Plan section?
This instrument is used to measure blood pressure.
What is a sphygmomanometer?
A fatty buildup inside an artery is known as this.
What is plaque?
This type of feedback loop amplifies or increases a response.
What is a positive feedback loop?
The ability to understand and share a patient’s feelings is called this.
What is empathy?
A physician asks about recent travel, medication use, and family history. This broader information is part of what overall component of patient care?
What is the medical history?
If a patient has 24 breaths per minute at rest, how would you classify this finding?
What is an elevated respiration rate (tachypnea/above normal)?
If a lab report shows elevated white blood cells, this could suggest what general type of condition?
What is infection (or inflammation)?
In Type I diabetes, the body has difficulty producing this hormone due to pancreatic dysfunction.
What is insulin?
Emailing patient records to a roommate without consent would be classified as what?
What is a HIPAA violation?