Study GuidesAs the medical assistant you play a role in the completenessof the patient’s medical history. Most office use either

  

Study GuidesAs the medical assistant you play a role in the completenessof the patient’s medical history. Most office use either the SOAP/SOAPER or CHEDDER method to document the medical history in the medical record. You are going to practice one of these documentation methods by creating a fake patient, complaint, and responses to one of the above choices (SOAP/SOAPER or CHEDDER).EXAMPLES AS PROVIDED:Wolter PethokoukisDate of Birth: 01/22/1949Visit Date: 04/04/20XXS: Patient returns after undergoing upper Gl: not in as much discomfort os lastvisit. Stales he has been loking clear liquids and solf loos. Soys he ishungry.O: Lob results are back. Chem 7 shows slightly elevated glucose at 133. CBCand UA normal. Upper GI shows two small areas of ulceration.A: Gastric ulcer.P: Reduce omeprazole to 10 mg every day. Recheck glucose at refurn visit in 4 weeks.E: Patient was advised not to smoke or chew tobacco, limit alcohol intake, and avoid aspirin, ibuprofen, and naproxen. Try acetaminophen instead. No diet restrictions indicated.R: Patient was relieved indicates there is no problem following the above plan and recommendation. Health Science Science Nursing Share (0)