| A | B |
|---|
| assessment | The physician's interpretation of subjective and objective findings as contained in the SOAP record; also called "diagnosis" or "impression." |
| chief complaint (CC) | The reason for the patient's visit to seek the physician's advice. |
| diagnosis (DX) | A term used interchangeably with "assessment" or "impression;" gives a name to the condition from which the patient is suffering. |
| family history (FH) | Facts about the health of the patient's parents, siblings, and other blood relatives that might be significant to the patient's condition. |
| history of present illness (HPI) | Information taken from the patient about symptoms; when they began, what factors affect them, what the patient thinks is the cause, remedies tried, and any past treatment for the symptoms. |
| impression | A term used interchangeably with "assessment" or "diagnosis;" gives a name to the condition from which the patient is suffering. |
| objective | The physician's examination of the patient contained in the SOAP record; results of the examination may be shown under the heading of "Physical Examination (PE)." |
| past medical history (PMH) | A listing of any illnesses the patient may have had in the past; includes treatments and procedures performed. |
| physical exam (PE) | A complete examination of the patient in which findings for each of the major areas of the body are stated on an examination that covers only the body systems pertinent to that particular visit. |
| plan | The treatment, as stated in the SOAP record, listing prescribed medication, instructions given to the patient, recommendation for surgery or hospitalization. |
| problem-oriented medical record | (POMR) A patient record organized around a list of the patient's complaints or problems; contains a database of the patient's history, initial plan, and problem list. |
| review of systems (ROS) | The physician's specific questions to the patient about each of the body's systems. |
| rule out (R/O) | A possible diagnosis that must be proved or "ruled out" by further tests. |
| SOAP | An acronym used to refer to the most common system for outlining and structuring notes on a patient's chart; the acronym stands for the headings used: Subjective, Objective, Assessment, and Plan. |
| social history (SH) | Information that may be pertinent to treatment regarding the patient's marital history, occupation, interests, and eating, drinking, smoking habits. |
| subjective | The patient's description of the problem or complaint including symptoms,when symptoms began, associated factors. remedies tried, and past medical history. |
