racheal's crossword

2. a subjective, or internal condition felt by a patient
4. complaint the patient's main issue of pain or ailment
7. diagnosis or impression of a patient's problem
8. each condition or diagnosis a patient has is listed separately and given it's own number
9. patient health record created and stored on a computer
10. makes it easier for the physician to keep track of a patient's progress
11. a health record that provides a summary of medical information
14. inventory of the body obtained by the healthcare provider through a series of questions
16. one of the 6 c's of charting
17. a collection of records created and stored on a computer
18. contains important information about a patient's medical history and present condition
22. contains the patient's past medical history surgeries allergies current medications
24. to suit a specific specialty and style of a physician's office
25. the last part in the soap documentation

1. the recording of information in a patient's medical record
3. pertaining to data that are readily apparent and measurable, such as vital signs test results or physical examination findings
5. the transforming of spoken notes into accurate written form
6. to examine and review a group of patient records for completeness and accuracy
9. record of health related information for an individual patient
12. patient information is arranged
13. data come from the physician examinations and test results
15. statistical data relating to the population and particular groups within it
19. a patient who does not follow the medical advice given
20. takes the soap format further breaking it down into smaller components
21. - data come from the patient
23. an objective or external factor, such as blood pressure, rash or swelling