Chapter 2 Flashcards

1
Q

SOAP

A

Subjective, Objective, Assessment, Plan

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2
Q

Subjective

A

What the patient describes

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3
Q

Objective

A

What the tests reveal

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4
Q

Assessment

A

The analysis of the subjective and objective information; a diagnosis

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5
Q

Plan

A

The course of action for the patient. Ex: Medication, physical therapy, surgery, etc.

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6
Q

Physician

A

A skilled health professional who attended and graduated medical school

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7
Q

Pediatrician

A

A physician with a special training in caring for children

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8
Q

Surgeon

A

A physician qualified to treat patients surgically

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9
Q

Anesthesiologist

A

A physician with special training in pain sedation and pain control

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10
Q

Physician assistant

A

A mid level health care provider who works under the license of a supervising physician

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11
Q

Nurse practitioner

A

A nurse with postgraduate training that serves as a mid level health care provider

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12
Q

Emergency medical technician (EMT)

A

Specially trained in the emergency care of a patient before and/or during transport to a medical facility

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13
Q

Speech therapist

A

Specially trained in evaluating and treating problems with speech and/or swallowing

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14
Q

Occupational therapist

A

Specially trained in evaluating and treating problems with performing daily activities at home, school, or work.

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15
Q

Physical therapist

A

Specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury

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16
Q

Respiratory therapist

A

Specially trained in treating patient’s respiratory issues under the guidance of a health care provider

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17
Q

Dietician

A

Specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan

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18
Q

Licensed practical nurse (LPN)

A

Trained and certified to provide basic care to a patient

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19
Q

Registered nurse (RN)

A

An advanced level nurse who has completed and associates or bachelors degree

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20
Q

Medical assistant

A

Trained to carry out basic administrative and clinical tasks under the guidance of a health care provider

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21
Q

Pathologist

A

A physician with special training in both evaluating the causes and effects of disease and in laboratory medicine

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22
Q

Medical laboratory technician

A

Trained in performing laboratory testing on bodily fluids

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23
Q

Phlebotomist

A

Trained int he removal of blood from the body for diagnostic or therapeutic purposes

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24
Q

Radiologist

A

A physician specially trained in evaluating images of the body to diagnose illness or injury

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25
Radiology technician
Trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
26
Ultrasonographer
Trained in performing ultrasound imaging on a patient
27
Pharmacist
Trained and licensed in preparing and dispensing medicine
28
Pharmacy technician
Trained to assist a pharmacist with pharmacy-related tasks
29
Patient service coordinator
Handles administrative tasks and coordinates patient care
30
Medical transcriptionist
Trained in converting the voice-recorded dictations of health care providers into text format
31
Chief complain
The main reason for the patient’s visit
32
History of present illness
The story of the patient’s problem
33
Review of systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem
34
Past medical history
Other significant past illnesses
35
Past surgical history
Any of the patient’s past surgeries
36
Family history
Any significant illnesses that run in the patient’s family
37
Social history
A record of habits like smoking, drinking, drug use, and sexual practices that can impact health
38
(R)
Right
39
(L)
Left
40
(B)
bilateral (both sides)
41
VS
Vital signs
42
HR
heart rate
43
RR
Respiratory rate
44
BP
Blood pressure
45
T
Temperature
46
Ht
Height
47
Wt
Weight
48
BMI
Body Mass Index
49
I/O
Input/output
50
Dx
Diagnosis
51
DDx
Differential diagnosis
52
Tx
Treatment
53
Rx
Prescription
54
Hx
History
55
PMHx
Past medical history
56
FHx
Family history
57
H&P
History and physical
58
CC
Chief complaint
59
HPI
History of present illness
60
ROS
Review of systems
61
PE
Physical exam
62
PCP
Primary care provider
63
NKDA
No known drug allergies
64
Pt
Patient
65
Y/o
Years old
66
h/o
History of
67
f/u
Follow up
68
NAD
No acute distress
69
NOS
Not otherwise specified
70
RRR
Regular rate and rhythm
71
CTA
Clear to auscultation
72
A&O
Alert and oriented
73
PERRLA
Pupils equal, round, and reactive to light and accommodation
74
PO
per os (by mouth)
75
IV
Intravenous
76
SC
Subcutaneous
77
CVL
Central venous line
78
IM
Intramuscular
79
PR
per rectum (anal)
80
NPO
Nil per os (nothing by mouth)
81
BID
Twice daily
82
TID
Three times daily
83
Q4hr
Every 4 hours
84
QD
Daily
85
QID
4 Times daily
86
QHS
At night
87
AC
before meals
88
PC
After meals
89
prn
As needed
90
Ad lib
As desired