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SOAP note section–specific terms for health care records
This is an excerpt from The Medical Terminology Book by Laura S. Kabiri.
Ready to learn some of the most common general (that is, not associated with one particular body system) complaints heard in health care and their medical terminology equivalents? Yeah, you are!
A few medical terms commonly used in the subjective, objective, assessment, and plan sections can be found in tables 2.2 to 2.5, respectively. Please note that these terms are not exclusive to one section! You may also see and use them elsewhere. I’m just trying to bring some order to things. And make it seem less intimidating by presenting in four LEE-tuhl tables instead of one JYE-ant table.
Please note the difference between a symptom in table 2.2 and a sign in table 2.3. While these terms are often used together (signs and symptoms), a symptom is something a patient tells you (subjective) while a sign is something you see (objective). For example, if a patient SAYS their nose is clogged but you SEE a nose clip on their nose, nasal congestion would be the SYMPTOM and the presence of a foreign object occluding the nasal passages (nose clip) would be the SIGN. By the way, remove that nose clip and . . . IT’S A MIRACLE!! They can smell once again.
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