mitc
19
glos

assessment
Gathering information; a step in charting that is the health care professional's impression of what is wrong with the patient, based on the signs and symptoms
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NOGRAPHIC

charting
Recording observations and information about patients
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NOGRAPHIC

chief complaint
The patient's statement of the main reason he or she is seeking medical care
NOAUDIO
NOGRAPHIC

medical documentation
Notes and documents that health care workers add to the medical record
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medical history
Data collected on a patient that includes personal, familial, and social information
NOAUDIO
NOGRAPHIC

medical record
The collection of all documents that are filed together and that form a complete chronological health history of a particular patient
NOAUDIO
NOGRAPHIC

plan
A step in SOAP charting that documents the procedures, treatments, and patient instructions that make up the patient's care
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NOGRAPHIC

progress notes
Written chronological statements about a patient's care
NOAUDIO
NOGRAPHIC

SOAP
A format for charting that uses a problem-oriented approach; stands for Subjective, Objective, Assessment, and Plan
NOAUDIO
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