Medical Terminology Mod 2 Course
Medical Terminology Mod 2 Course
In this course project assignment, you are presented with clinical notes for two different patients. These progress notes have been recorded as SOAP notes. A SOAP note is a common method of documenting a patient’s visit with a healthcare provider. These notes are saved in a patient’s medical record and will be used for treatment, billing, and other activities to monitor the patient’s health over time.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Each of these components is used to record a vital part of the patient’s visit.
Subjective: Includes the patient’s complaints and states the patient’s symptoms in his or her own words
Objective: Includes information that the provider can measure, such as vital signs, weight, or findings from a physical exam
Assessment: Includes a differential diagnosis or summary of signs and symptoms
Plan: Includes treatments performed, follow-up appointment information, referrals, or other orders
You will be exploring the medical terminology used in these SOAP notes and will be asked to interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
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Download the clinical notes for the two patients:
Kay Salisbury Clinical Notes (I have attached it below)
Virginia Thompson Clinical Notes (I have attached it below)
Download, complete, and submit the document below. This document contains questions you will answer regarding the clinical notes for each patient.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.