Goldwell Elumen Chart

Class Notes

What is SOAP?

1. S - Subjective (Component)

This describes the current condition of the patient in narrative form. This includes history, pharmacology, diseases and allergies. also a record of current and relevant symptoms should be noted.

2. O - Objective (Component)

· exposes vital signs

· Findings physical lifeless, like posture, strokes , abnormalities.

· laboratory results.

· Measures such as weight, height and age.

3. A - Assessment

is a summary of patient diagnosis, this should include a differential diagnosis if possible.

4. P - Plan

Here

health provider exposes medical treatment to follow, including preventive measures for possible future complications and / or distress in addition to the follow-up appointments.

Filmini Incesto Gratis

Medical Record Medical Record

UNIT I

A. Description of a clinical record

1. Sectional

2. Chronological

3. Order Form

4. Description Document (Sheets)

UNIT II

A. Importance of Record

1. Medical Staff

2. Respiratory Care

UNIT III

A. Types of Orders Medical

1. Speech

2. Written

3. Oral

B. criteria for accepting a medical order

1. Physician Order

i. Dose

ii. Thinner

iii. Therapeutic Modality

iv. Drug

v. Frequency

vi. Signature, Date and Time

2. Expiration Medical Orders

i. Importance

ii. Implementation of the cancellation of the order

UNIT IV

A. Construction Reports

1. Description of the Different Types of Tickets

i. Examples of Some Hospitals

2. Guides Questions Write

i. How do you get?

ii. What do you notice?

iii. Manage What?

iv. how to let it?

3. Legal Aspects

i. What is permitted to perform in a file

a) Use black ink

ii. He was not allowed in a file

a) Liquid Corridor

b) Drafts

c) studs

d) Let Information Important

iii. Privacy

a) Law HIPPA

b) VIP Patients

c) Law # 24 (legal issues)

iv. Taking a prescription

a) Reading order

b) Interpretation of order

c) Signature of medical order