EHR Soap Notes Study Case With Review Questions And Guaranteed Answers/2024.

Subjective - correct answer CC: main reason for visit. MA plays role in documenting subjective; 1st to write in chart Objective - correct answer Finding/observations found by MA, Nurse, or Dr. Ex: vital signs, height/weight, EKG, urinalysis, pregnancy test. Something physically seen on patient (See, hear, feel) Assessment - correct answer Doctors conclusion. Diagnosis and prognosis. Diagnosis - evidence to prove condition. Prognosis - an educated guess. Only the Doctor does assessments. Plan - correct answer Treatment, after car, recommendations, advice, prescriptions. Only the doctor does