Soap medical term

ALL PARTS HAVE TO BE COMPLETED

Part 1 100-200 words

Primary Task Response: A patient may be referred to a medical specialty clinic for treatment. For that visit, an outpatient specialty note is prepared that follows the pattern for most medical notes and records. The record is referred to as a SOAP note, which stands for subjective, objective, assessment and plan (SOAP). The clinician will review and document what the patient states is his/her problem or concern (subjective), perform an exam that might include laboratory tests and imaging studies and document the results (Objective), review and analyze the information (Assessment) as a diagnosis or list of possible diagnoses, and formulate a plan of action (Plan) such as treatment options or need for further testing. This becomes the record of that visit and a part of the patient’s electronic health record (EHR).

Click on the EHR Orthopedic Clinic Note link for this information and complete the assignment as follows: FIND LINK UNDER ATTACHEMENT NOTE

Read the EHR Orthopedic Clinic Note
Define the bolded terms and abbreviations in the EHR Orthopedic Clinic Note.
Summarize for the patient in your own words (laymen’s terms) what each section (subjective, objective, assessment and plan) of the Orthopedic Clinic note means.
What is the function of the musculoskeletal system?
Part 2 100-200 WORDS

Primary Task Response: When a patient is seen in the emergency department (ED) of a hospital, that visit is documented in an emergency department visit note. The ED note must be succinct, but complete. This is because the physician and patient encounter in the ED is the basis for continued care (admission or follow-up) by providers outside of the ED. It is also important for coding and billing that the information be accurate and complete in order to obtain proper reimbursement. This is true for all health records and documentation.