MAAP

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Author:
kmkulit
ID:
245345
Filename:
MAAP
Updated:
2013-11-06 01:48:53
Tags:
MAAP
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Description:
MAAP
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  1. SOAP
    • subjective
    • objective
    • assessment
    • plan
  2. subjective
    • chief complaint
    • what they state verbally is bothering them
    • reason why they came to see dr.
    • (ex. cold, runny nose)
  3. objective
    • observed during physical
    • vital signs
    • lab results
    • (ex. tenderness, wheezing, etc.)
  4. assessment
    • diagnoses (may be more than one)
    • organized by problem presented or organ system 
    • (ex. appendectomy)
  5. plan
    • treatment, med./surg. procedure, referrals, followup drug work, drugs, etc.
    • (ex. blood test, referral to psychiatrist)
  6. POMR
    problem oriented medical record

    example:

    • POMR                       Rx
    • 1. hypertension          AdalatXL30mg

    2. prediabetes           diet + exercise

    3. menopause           DEXA
  7. CC
    chief complaint

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