CPP 1101 Chapter Notes - Chapter 2: Differential Diagnosis, Medical Record, Sequela

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Chapter 2: introduction to health records: soap is an acronym that stands for the four general parts of a medical note, subjective. Includes the duration of the problem, quality of the problem, and any exacerbating or relieving factors for that problem: example: personal experiences and family medical history, objective. Comprise the patient"s physical exam, any laboratory findings, and imaging studies performed at the visit: assessment. An identification of a problem, or a list of possibilities for the diagnosis; differential diagnosis: plan. A course of action consistent with his or her assessment: treatment with medicine or procedure, scrutinize, studies, subjective, survey. Description of individual body systems in order to discover any symptoms not directly related to the main problem. Other significant past illnesses, like high blood pressure, asthma, or diabetes. Any significant illnesses that run in the patient"s family. A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health.

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