MA Chapter 3 Flashcards by Tazneem Hinnawi

Q

EMR

A

Electronic medical record (one facility)

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Q

EHR

A

Electronic health record (multiple)

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Q

Chief complaint

A

Main reason for visit

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Q

NKDA

A

No known drug allergies

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Q

Diagnosis

A

Providing decided issue

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Q

Prognosis

A

Provider prediction of issue

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Q

Superficial Pain

A

On the bodies surface

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Q

Deep pain

A

Into the muscles, joints, and tendons

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Q

Visceral pain

A

Organ pain, most severe

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Q

Psychological pain

A

Mental/emotional pain

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Q

Phantom pain

A

Result of amputation of limb or removal of organ

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Q

Anaphylaxis

A

Harmful reaction due to allergen

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Q

What is SOAP used for

A

EMR sys universal template to gather and document pt info

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Q

What does SOAP stand for

A

Subjective (pt)
Objective (MA)
Assessment (Dr.)
Plan (everyone)

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Q

What does S in SOAP mean?

A

The pt stated symptoms in their own words

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Q

What does O in SOAP mean?

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A

MA’s observation, vital signs, and documention

Q

What does A in SOAP mean?

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A

The providers diagnosis/prognosis

Q

What does P in SOAP mean?

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A

The course of action for treatment

Q

Onset

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A

Acute (suddenly) or chronic (over time) pain