ch. 2 Flashcards
1
Q
health records
A
contain info about patient Previous illnesses and treatments Continuing medical problems History of family illnesses Current medications The health record contains the data that will determine the patient’s care plan.
2
Q
SOAP Method
A
four different types of information documented by health care providers in a medical note: S = Subjective: what the patient says O = Objective: what the tests reveal A = Assessment: the analysis of the subjective and objective information; performed by the health care provider P = Plan: the course of action for the patient
3
Q
Subjective
A
These are the problems that the patient states
he/she has.
Those problems are then translated into medical
terms.
This is so that you can correctly communicate the
problems to all health care providers
4
Q
Objective
A
This is the data collected by the health care
provider.
This information also includes data obtained from
lab tests or special images of the patient’s body.
5
Q
Assessment
A
This is the combination of the subjective and
objective information.
This information leads to a conclusion about the problem
known as the diagnosis.
If a single cause isn’t evident, a differential diagnosis—a
list of the most likely causes—may be needed.
6
Q
Plan
A
The plan is what the provider recommends to the
patient regarding their current health status.
This can include medication, surgery, and/or
further tests, among other options.
7
Q
Acute
A
just started, very sharp, sudden onset, time period varie
8
Q
Chronic
A
long term, going on for a long time, time period varies
9
Q
Abrupt
A
sudden
10
Q
Febrile
A
have a fever
11
Q
afebrile
A
don’t have a fever
12
Q
malaise
A
not feeling well
13
Q
progressive
A
more and more
14
Q
exacerbation
A
things are getting worse
15
Q
symptom
A
something the patient feels
16
Q
noncontributory
A
unrelated
17
Q
lethargic
A
sluggish, decrease in level of consciousness
18
Q
genetic/hereditary
A
got it from ancestors
19
Q
Alert
A
awake and responsive
20
Q
oriented
A
knows who where and when (A and O times 3)
21
Q
Auscultation
A
to listen
22
Q
Percussion
A
hit and listen, feel for vibration
23
Q
Palpation
A
to feel
24
Q
Unremarkable
A
nothing remarkable, dont see anything
25
Marked
stands out
26
Impression
your assessment
27
Diagnosis
what you think is going on
28
Differential Diagnosis
list of possible diagnosis
29
Benign
safe
30
Malignant
dangerous
31
Degeneration
getting worse
32
Etiology
cause
33
Idiopathic
no known cause
34
Remission
to get better or improve, not a cure!
35
Recurrent
to have again
36
Morbidity
risk for being sick
37
Mortality
risk for dying
38
Prognosis
chance of getting better or worse
39
Localized
stays in a certain area/part
40
Systemic/generalized
all over
41
occult
hidden
42
pathogen
organism causing a problem
43
lesion
diseased tissue
44
sequelae
problem from a disease or injury
45
pending
waiting for
46
disposition
what happened at end of visit
47
discharge
send home, or sent to alternative place (hospice, nursing home, rehab, medical housing etc)
48
Prophylaxis
preventative treatment
49
palliative
treatment for symptoms only
50
observation
to watch
51
reassurance
to tell patient it's prob not serious
52
supportive care
treatment for symptoms, mental health profs, social work help etc
53
sterile
clean, germ free
54
proximal
apply to limbs, closer to trunk
55
distal
apply to limbs, further from trunk
56
anterior
toward front
57
posterior
toward back
58
ventral
front
59
dorsal
back
60
medial
toward central
61
lateral
away from central
62
superior
toward top
63
inferior
toward back
64
supine
flat on back
65
pront
flat on stomach
66
contralateral
opposite side LOOK UP
67
ipsalateral
same side LOOK UP
68
dorsum
top of hand or foot
69
palmar
palm of hand
70
plantar
bottom of foot
71
coronal plane
divides you into front and backside
72
Transverse plane
can be anywhere from top to bottom of your body
73
Sagittal plane
down your body in line with spine
74
physician
a skilled health care provider who attended and graduated
medical school; There are two types in America: medical
doctor (MD) and doctor of osteopathy (DO).
75
pediatrician
a physician with special training in caring for children
76
surgeon
a physician qualified to treat patients surgically, that is, by
means of operation or invasive procedure
77
anesthesiologist
a physician with special training in pain sedation and pain
| control
78
physician assistant (PA)
a midlevel health care provider who works under the license
| of a supervising physician; requires postgraduate training
79
nurse practitioner (NP)
a nurse with postgraduate training that serves as a midlevel
health care provider; works under the license of a
supervising physician
80
emergency medical technician (EMT)
specially trained in the emergency care of a patient before
| and/or during transport to medical facility
81
speech therapist
specially trained in evaluating and treating problems with
| speech and/or swallowing
82
occupational therapist
specially trained in evaluating and treating problems with
| performing daily activities at home, school, or work
83
physical therapist
specially trained in evaluating and treating physical
| impairments including disabilities or recovery from an injury
84
respiratory therapist
specially trained in treating patient’s respiratory issues under
the guidance of a health care provider
85
dietician
specially trained in evaluating the nutritional status of a patient
and developing an appropriate diet plan
86
licensed practical nurse (LPN)
trained and certified to provide basic care to a patient
87
licensed vocational nurse (LVN)
LOOK UP
88
registered nurse (RN)
an advanced level nurse who has completed an associate’s or
bachelor’s degree; often assists with patient care planning and
patient education
89
medical assistant
trained to carry out basic administrative and clinical tasks
| under the guidance of a health care provider
90
pathologist
a physician with special training in both evaluating the causes
and effects of disease and in laboratory medicine
91
medical laboratory technician
trained in performing laboratory testing on bodily fluids
92
phlebotomist
trained in the removal of blood from the body for diagnostic or
therapeutic purposes
93
radiologist
a physician specially trained in evaluating images of the body to
diagnose illness or injury
94
radiology technician
trained to perform radiologic testing or administer radiation
therapy under the direction of a health care provider
95
ultrasonagrapher
trained in performing ultrasound imaging on a patient
96
pharmacist
trained and licensed in preparing and dispensing
| medicine
97
pharmacy technician
trained to assist a pharmacist with pharmacy-related
| tasks
98
patient service coordinator
handles administrative tasks and coordinates patient care
99
medical transcriptionist
trained in converting the voice-recorded dictations of health care providers into text format
100
Chief complaint
The main reason for the patient’s visit
101
History of present illness
The story of the patient’s problem
102
Review of systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem
103
Past medical history
Other significant past illnesses, like high blood pressure, asthma, or diabetes
104
Past surgical history
Any of the patient’s past surgeries
105
Family history
Any significant illnesses that run in the patient’s family
106
Social history
A record of habits like smoking, drinking, drug
abuse, and sexual practices that can impact
health
107
Pre-op
before surgery
108
OR
operating room
109
PACU
post anesthesia care unit
110
Post-op
after surcery
111
ICU
intensive care unit
112
CCU
coronary care unit (cardiovasc sys)
113
SICU
surgical intensive care unit
114
PICU
pediatric intensive care unit
115
NICU
neonatal intensive care unit
116
ER
emergency room
117
ED
emergency dept
118
ECU
emergency care unit
119
L&D
labor and delivery
120
VS
vital signs
121
RR
respiratory rate
122
BP
blood pressure
123
T
temp
124
Ht
height
125
Wt
weight
126
BMI
body mass index
127
I/O
intake and output
128
Dx
diagnosis
129
DDx
differential diagnosis
130
Tx
treatment
131
Rx
prescription
132
Hx
history
133
PMHx
prior medical or past medical history
134
FHx
fam history
135
H&P
history and physical
136
CC
chief complaint
137
HPI
history of present illness
138
ROS
review of systems
139
PE
physical exam
140
PCP
primary care physician
141
NKDA
no known drug allergies
142
Pt
patient
143
y/o
years old
144
h/o
history of
145
f/u
follow up
146
PERRLA
pupils equal, round, and reactive to light
| and accommodation
147
NOS
not otherwise specified
148
RRR
regular rate and rhythm
149
CTA
clear to auscultation
150
A&O
alert and oriented
151
NAD
no acute distress
152
PO
per os (by mouth)
153
IV
intravenous
154
SC
subcutaneous
155
CVL
central venous line
156
IM
intramuscular
157
PR
per rectum (anal), usually when have severe nausea/vomiting
158
NPO
nil per os (nothing by
| mouth)
159
prn
as needed
160
QID
four times a day
161
QD
everyday
162
AC
before meals
163
TID
three times a day
164
BID
twice a day
165
PC
after meals
166
QHS
at night
