Ch. 2: Intro to Health Records Flashcards
What does SOAP stand for?
subjective
objective
assessment
plan
How a patient experiences and personally describes his or her problem, as well as personal and family medical histories.
subjective
Data comprised of the physical exam, lab findings, and imaging studies.
objective
A logical analysis (identify a problem, or a list of possibilities for the diagnosis).
assessment
A course of action consistent with an assessment.
plan
acute
ah-KYOOT
the problem just started recently, or is a sharp, severe symptom
chronic
KRaH-nik
the problem has been going on for a while now
exacerbation
ex-SAS-er-BAY-shun
the problem is getting worse
abrupt
ah-BRUPT
all of a sudden
febrile
FEH-brail
to have a fever
afebrile
AY-FEH-brail
to not have a fever
malaise
mah-LAYZ
not feeling well
progressive
proh-GREH-siv
more and more each day
symptom
SIM-tom
something a patient feels
noncontributory
NON-kon-TRIB-yoo-TOH-ree
not related to this specific problem
lethargic
lah-THAR-jik
a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick
genetic
hereditary
jih-NEH-tik
hah-REH-dih-TEH-ree
a problem runs in the family
alert
ah-LERT
able to answer questions; responsive; interactive
oriented
OR-ee-EN-ted
being aware of who he or she is where he or she is, and the current time; a patient who is aware of all three is “oriented x3”
marked
MARKT
something really stands out
unremarkable
un-ree-MARK-ah-bul
another way of saying normal
auscultation
aws-kul-TAY-shun
to listen
percussion
per-KUH-shun
to hit something and listen to the resulting sound or feel for the resulting vibration
palpation
pal-PAY-shun
to feel
impression
im-PREH-shun
another way of saying assessment
diagnosis
DAI-ag-NOH-sis
what the heath care professional thinks the patient has
differential diagnosis
dih-ger-EN-shal DAI-ag-NOH-sis
a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
benign
beh-NAIN
safe
malignant
mah-LIG-nant
dangerous; a problem
degeneration
dee-jen-er-AY-shun
to be getting worse
etiology
eh-tee-AW-loh-jee
the cause
remission
reh-MIH-shun
to get better or improve; most often used when discussion cancer, remission does not mean cure
idiopathic
ih-dee-oh-PA-thik
no known specific cause, it just happens
localized
LOH-kah-LAIZD
stays in a certain part of the body
systemic
generalized
sih-STEM-ik
jen-er-ah-LAIZD
all over the body (or most of it)
morbidity
mor-BID-ih-tee
the risk for being sick
mortality
mor-TA-lih-tee
the risk for dying
prognosis
prawg-NOH-sis
the chances for things getting better or worse
occult
ah-KULT
hidden
pathogen
PATH-oh-jin
the organism that causes the problem
lesion
LEE-shun
diseased tissue
recurrent
ree-KUR-ent
to have again
sequelae
seh-KWEL-ah
a problem resulting from a disease or injury
pending
PEN-ding
waiting for
disposition
dis-poh-ZIH-shun
what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU normal hospital bed, etc)
discharge
DIS-charj
literally, to unload
1. to send home
2. fluid coming out of a part of the body
prophylaxis
PROH-fuh-LAK-sis
preventative treatment
palliative
PA-lee-ah-tiv
treating the symptoms, but not actually getting rid of the cause
observation
OB-zer-VAY-shun
to watch or keep an eye on
reassurance
ree-ah-SHUR-ants
to tell the patient that the problem is not serious or dangerous
supportive care
suh-POR-tiv kehr
to treat the symptoms and make the patient feel better
sterile
STEH-ril
extremely clean, germ-free conditions; especially important during medical procedures and surgery
proximal
PRAWK-sih-mal
closer in to the center
proximal and approximate come from the same word and mean close
distal
DIH-stal
farther away from the center
distal and distant come from the same word and mean far
lateral
LA-ter-al
out to the side
think of a quarterback lateraling a football to a running back
medial
MEE-dee-al
toward the middle
like the median of a highway
ventral
antral
anterior
VEN-tral AN-tral an-TIH-ree-or the front the word ventral means "stomach"
dorsal
posterior
DOR-sal
pohs-TEER-ee-or
the back
a dorsal fin on a shark is on its back
cranial
KRAY-nee-al
toward the top
caudal
KOW-dal
toward the bottom
from Latin for tail
superior
soo-PIH-ree-or
above
inferior
in-FIH-ree-or
below
prone
PROHN
lying down on belly
supine
SOO-pain
lying down on back
contralateral
KON-tra-LA-ter-al
opposite side
ipsilateral
IP-sih-LA-ter-al
same side
unilater
YOO-nih-LA-ter-al
one side
bilateral
BAI-LA-ter-al
both sides
dorsum
DOR-sum
the top of the hand or foot
plantar
PLAN-tar
the sole of the foot
palmar
PAL-mar
the palm of the hand
sagittal
SA-jih-tal
divides the body in right and left slices
sagitta is Latin for arrow; think of this as dividing the body in half, as if someone shot an arrow through it
coronal (frontal)
kah-ROH-nal
divides the body in front and back slicces
corona is Latin for crown; this plane divides the body in half from the top of the head down
transverse
tranz-VERS
divides the body from top to bottom
physician
fuh-ZIH-shun
a skilled health care provider who attended and graduated medical school (MD medical doctor and DO doctor of osteopathy)
pediatrician
PEE-dee-ah-TRIH-shun
a physician with special training in caring for children
surgeon
SIR-jen
a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure
anesthesiologist
AN-ehs-THEE-zee-AWloh-jist
a physician with special training in pain sedation and pain control
physician assistant (PA)
fuh-ZIH-shun as-SIS-tant
a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training
nurse practitioner (NP)
NIRS prak-TIH-shuh-ner
a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician
emergency medical technician (EMT)
eh-MIR-jen-see MEH-dih-kal tek-NIH-shun
specially trained in the emergency care of a patient before and/or during transport to medical facility
speech therapist
SPEECH THEH-rah-pist
specially trained in evaluating and treating problems with speech and/or swallowing
occupational therapist
aw-kyoo-PAY-shuh-nal THEH-rah-pist
specially trained in evaluation and treating problems with performing daily activities at home, school, or work
physical therapist
FIH-sih-kal THEH-rah-pist
specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury
respiratory therapist
reh-sprah-TOR-ee THEH-rah-pist
specially trained in evaluating and treating patient’s respiratory issues under the guidance of a health care provider
dietician
dai-ah-TIH-shun
specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan
licensed practical nurse (LPN)
licensed vocational nurse (LVN)
LAI-senzd PRaK-tih-kal NIRS
LAI-senzd voh-KAY-shun-al NIRS
trained and certified to provide basic care to a patient
registered nurse (RN)
REH-jis-terd NIRS
an advanced level nurse who has completed an associate’s or bachelor’s degree; often assists with patient care planning and patient education
medical assistant
MEH-di-kal ah-SIS-tant
trained to carry out basic administrative and clinical tasks under the guidance of a health care provider
pathologist
pah-THAW-loh-jist
a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
medical laboratory technician
med-DIH-kal LAH-broh-tor-ee tek-NIH-shun
trained in performing laboratory testing on bodily fluids
phlebotomist
fleh-BOH-tow-mist
trained in the removal of blood from the body for diagnostic or therapeutic purposes
radiologist
ray-dee-AW-loh-jist
a physician specially trained in evaluating images of the body to diagnose illness or injury
radiology technician
ray-dee-AW-loh-jee tek-NIH-shun
trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
ultrasonographer
ul-trah-saw-NAW-grah-fir
trained in performing ultrasound imaging on a patient
pharmacist
FAR-mah-sist
trained and licensed in preparing and dispensing medicine
pharmacy technician
FAR-mah-see tek-NIH-shun
trained to assist pharmacist with pharmacy-related tasks
patient service coordinator
PAY-shent SIR-vis coh-OR-dih-nay-tor
handles administrative tasks and coordinates patient care
medical transcriptionist
MEH-dih-kal tran-SKRIP-shun-ist
trained in converting the voice-recorded dictations of health care providers into text format
chief complaint
the main reason for the patient’s visit
history of present illness
the story of the patient’s problem
review of systems
description of individual body systems in order to discover any symptoms not directly related to the main problem
past medical history
other significant past illnesses, like HBP, asthma, or diabetes
past surgical history
any of the patient’s past surgeries
family history
any significant illnesses that run in the patient’s family
social history
a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
CCU
coronary care unit
ECU
emergency care unit
ER
emergency room
ED
emergency department
ICU
intensive care unit
PICU
pediatric intensive care unit
NICU
neonatal intensive care unit
SICU
surgical intensive care unit
PACU
post-anesthesia intensive care unit
L&D
labor and delivery
OR
operating room
post-op
after surgery
pre-op
before surgery
VS
vital signs
T
temperature
BP
blood pressure
HR
heart rate
RR
respiratory rate
Ht
height
Wt
weight
BMI
body mass index
I/O
intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)
Dx
diagnosis
DDx
differential diagnosis
Tx
treatment
Rx
prescription
H&P
history and physical
Hx
history
CC
chief complaint
HPI
history of present illness
ROS
review of systems
PMHx
present medical history
FHx
family history
NKDA
no known drug allergies
PE
physical exam
Pt
patient
y/o
years old
h/o
history of
PCP
primary care provider
f/u
follow up
SOB
shortness of breath or SOA shortness of air
HEENT
head, eyes, ears, nose, and throat
PERRLA
pupils equal, round, reactive to light and accommodation
NAD
no acute distress
CV
cardiovascualr
RRR
regular rate and rhythm
CTA
clear to auscultation
WDWN
well developed, well nourished
A&O
alert and oriented
WNL
within normal limits
NOS
not otherwise specified
NEC
not elsewhere classified
PO
per os (by mouth)
NPO
nil per os (nothing by mouth)
PR
per rectum
IM
intramuscular
SC
subcutaneous
IV
intravenous
CVL
central venous line
PICC
peripherally inserted central catheter
Sig
instructions
BID
twice daily
TID
three times daily
Q
every x
QD
daily
QID
four times daily
QHS
at night
AC
before meals
PC
after meals
prn
as needed
ad lib
as desired
