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MED-121 > Chapter 2 > Flashcards

Chapter 2 Flashcards

Introduction to Health Records

1
Q

The SOAP Method

A

S = Subjective
O = Objective
A = Assessment
P = Plan

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2
Q

Subjective
The “S”OAP Method

A

What the patient says.
Problems that the patient states they have, then translated into medical terms:
- main reason for health visit
- description of the problem
- timing of the problem
- previous medical history
- family medical history
- current medication and allergies

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3
Q

Objective
The S”O”AP Method

A

What the tests reveal.
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,

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4
Q

Assessment
The SO”A”P Method

A

The analysis of the subjective and objective information; performed by the health care provider.
This is the combination of the subjective and objective information.
This information leads to a conclusion about the problem known as the diagnosis.

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5
Q

Plan
The SOA”P” Method

A

The course of action for the patient.
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.

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6
Q

cranial
KRAY-nee-al

A

toward the top

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7
Q

proximal
PRAWK-sih-mal

A

closer in to the center
proximal and approximate come from the same word and mean close

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8
Q

distal
DIS-tal

A

farther away from the center
distal and distant come from the same word and mean far

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9
Q

caudal
KAWD-al

A

toward the bottom
from Latin, for tail

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10
Q

inferior
in-FEER-ee-or

A

below

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11
Q

superior
soo-PEE-ree-or

A

above

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12
Q

supine
SOO-pain

A

lying down on back

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13
Q

prone
PROHN

A

lying down on belly

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14
Q

contralateral
KON-trah-LAT-eh-ral

A

opposite side

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15
Q

lateral
LAT-er-al

A

out to the side
think of a quaterback lateraling a football to a running back

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16
Q

medial
MEED-ee-al

A

toward the middle
like to the median of a highway

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17
Q

ventral/antral/anterior
VEN-tral / AN-tral / an-TEER-ee-or

A

the front
the word ventral means “stomach”

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18
Q

dorsal/posterior
DOR-sal / pos-TEE-ree-or

A

the back
a dorsal fin on a shark is on its back

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19
Q

ipsilateral
IP-sih-LAT-eh-ral

A

same side

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20
Q

unilateral
YOO-nih-LAT-er-al

A

one side

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21
Q

bilateral
bai-LAT-eh-ral

A

both sides

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22
Q

dorsum
DOR-sum

A

the top of the hand or foot

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23
Q

palmar
PAL-mar

A

the palm of the hand

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24
Q

plantar
PLANT-ar

A

the sole of the foot

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25
Q

physician
fih-ZISH-un

A

a skilled health care provider who attended and graduated medical school
There are two types who practice in America: medical doctor (MD) and doctor of osteopathy (DO)

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26
Q

pediatrician
pee-dee-ah-TRISH-un

A

a physician with special training in caring for children

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27
Q

surgeon
SIR-jen

A

a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure

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28
Q

anesthesiologist
AN-es-THEE-zee-AWL-oh-jist

A

a physician with special training in pain sedation and pain control

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29
Q

epidemiologist
EP-ih-DEE-mee-AWL-uh-jist

A

a specialist in the study of causes and distribution of diseases in populations and the use of this data to enhance public health

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30
Q

physician assistant (PA)
fih-ZISH-un ah-SIS-tant

A

a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training

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31
Q

nurse practitioner (NP)
NIRS prak-TISH-ih-ner

A

a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician

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32
Q

emergency medical technician (EMT)
eh-MIR-jen-see MED-ih-kal tek-NISH-un

A

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

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33
Q

speech therapist
SPEECH THER-ah-pist

A

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

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34
Q

occupational therapist
aw-kyoo-PAY-shuh-nal THER-ah-pist

A

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

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35
Q

physical therapist
FIZ-ih-kal THER-ah-pist

A

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

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36
Q

respiratory therapist
res-PIR-ah-toh-ree THER-ah-pist

A

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

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37
Q

dietician
dai-ah-TIH-shun

A

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

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38
Q

licensed practical nurse (LPN) / licenced vocational nurse (LVN)

A

trained and certified to provide basic care to a patient

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39
Q

registered nurse (RN)
REH-jis-terd NIRS

A

an advanced level nurse who has completed an associate’s or bachelor’s degree; often assists with patient care planning and patient education

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40
Q

medical assistant
MED-ih-kal ah-SIS-tant

A

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

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41
Q

pathologist
pah-THAWL-oh-jist

A

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

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42
Q

medical laboratory technician
MED-ih-kal LAB-rah-TOR-ee tek-NISH-un

A

trained in performing laboratory testing on bodily fluids

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43
Q

phlebotomist
fle-BAWT-oh-mist

A

trained in the removal of blood from the body for diagnostic or therapeutic purposes

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44
Q

radiologist
ray-dee-AWL-oh-just

A

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

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45
Q

radiology technician
ray-dee-AWL-oh-jee tek-NISH-un

A

trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider

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46
Q

ultrasonagrapher
UL-trah-soh-NAWG-rah-fer

A

trained in performing ultrasound imaging on a patient

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47
Q

pharmacist
FAR-mah-sist

A

trained and licensed in preparing and dispensing medicine

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48
Q

pharmacy technician
FAR-mah-see tek-NISH-un

A

trained to assist a pharmacist with pharmacy-related tasks

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49
Q

patient service coordinator
PAY-shent SIR-vis coh-OR-dih-nay-tor

A

handles administrative tasks and coordinates patient care

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50
Q

medical transcriptionist
MED-ih-kal tranz-KRIP-shon-ist

A

trained in converting the voice-recorded dictations of health care providers into text format

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51
Q

Chief complaint

A

The main reason for the patient’s visit

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52
Q

History of present illness

A

The story of the patient’s problem

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53
Q

Review of systems

A

Description of individual body systems in order to discover any symptoms not directly related to the main problem

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54
Q

Past medical history

A

Other significant past illnesses, like high blood pressure, asthma, or diabetes

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55
Q

Past surgical history

A

Any of the patient’s past surgeries

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56
Q

Family history

A

Any significant illnesses that run in the patient’s family

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57
Q

Social history

A

A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

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58
Q

acute
ah-KYOOT

A

it just started recently or is a sharp, severe symptom

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59
Q

chronic
KRAWN-ik

A

it has been going on for a while

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60
Q

exacerbation
eks-AS-er-BAY-shun

A

it is getting worse

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61
Q

abrupt
ah-BRUPT

A

all of a sudden

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62
Q

febrile
FEH-brail

A

to have a fever

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63
Q

afebrile
uh-FEB-ril

A

to not have a fever

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64
Q

malaise
mah-LAYZ

A

not feeling well

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65
Q

progressive
proh-GREH-siv

A

more and more each day

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66
Q

symptom
SIM-tom

A

something a patient feels

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67
Q

noncontributory
NON-kon-TRIH-byoo-TOR-ee

A

not related to this specific problem

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68
Q

lethargic
lah-THAR-jik

A

a decrease in level of consciousness; in medical record, this is generally an indication that the patient is really sick

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69
Q

genetic/hereditary
jen-ET-ik / heh-RED-ih-TER-ee

A

it runs in the family

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70
Q

alert
ah-LERT

A

able to answer questions; responsive; interactive

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71
Q

oriented
OR-ee-EN-ted

A

being aware of who they are, where they are, and the current time; a patient who is aware of all three is “oriented x3”

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72
Q

marked
MARKT

A

it really stands out

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73
Q

unremarkable
un-ree-MAR-kah-bul

A

another way of saying normal

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74
Q

auscultation
aw-skul-TAY-shun

A

to listen

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75
Q

percussion
per-KUSH-un

A

to hit something and listen to the resulting sound or feeling for the resulting vibration; drums are a percussion instrument

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76
Q

palpation
pal-PAY-shun

A

to feel

77
Q

impression
im-PRESH-un

A

another way saying assessment

78
Q

diagnosis
DAI-ag-NOH-sis

A

what the health care professional thinks the patient has

79
Q

differential diagnosis
DIF-eh-REN-chal-DAI-ag-NOH-sis

A

a list of conditions the patient may have based on the sympotms exhibited and the results of the exam

80
Q

benign
beh-NAIN

A

safe

81
Q

malignant
mah-LIG-nant

A

dangerous, a problem

82
Q

degeneration
dee-JEN-eh-RAY-shun

A

to be getting worse

83
Q

remission
rih-MISH-un

A

to get better or improve; most often use when discussing cancer; remission does not mean cure

84
Q

idiopathic
ID-ee-oh-PATH-ik

A

no known specific cause; it just happens

85
Q

localized
LOH-kal-aized

A

stays in a certain part of the body

86
Q

systemic/generalized
sis-TEM-ik / JEN-ral-aized

A

all over the body (or most of it)

87
Q

prognosis
prawg-NOH-sis

A

the chances for things getting better or worse

88
Q

occult
ah-KULT

A

hidden

89
Q

lesion
LEE-zhun

A

diseased tissue

90
Q

recurrent
rih-KUR-ent

A

to have again

91
Q

sequela
seh-KWEL-eh

A

a problem resulting from a disease or injury

92
Q

pending
PEN-ding

A

waiting for

93
Q

pathogen
PATH-oh-jen

A

the organism that causes the problem

94
Q

morbidity
mor-BID-it-ee

A

the risk for being sick

95
Q

mortality
mor-TAL-it-ee

A

the risk for dying

96
Q

etiology
EET-ee-AWL-oh-jee

A

the cause

97
Q

disposition
dis-poh-ZISH-un

A

what happened to the patient at the end of the visit; often used at the end of teh ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed)

98
Q

discharge
DIS-charj

A

literally, to unload; it has 2 meanings:
1. to send home (to unload the patient from the health care setting to home)
2. fluid coming out of the body (your body unloading a fluid)

99
Q

palliative
PAL-ee-AH-tiv

A

treating the symptoms, but not actually getting rid of the cause

100
Q

observation
OB-zer-VAY-shun

A

watch, keep an eye on

101
Q

reassurance
REE-ah-SHUR-ants

A

to tell the patient that the problem is not serious or dangerous

102
Q

supportive care
suh-POR-tiv kehr

A

to treat the symptoms and make the patient feel better

103
Q

sterile
STER-ul

A

extremely clean, germ-free conditions; especially important during medical procedures and surgery

104
Q

prophylaxis
proh-fih-LAK-sis

A

preventative treatment

105
Q

sagittal
SAJ-ih-tal

A

divides the body along a hypothetical plane from right to left
sagitta is Latin for arrow; think of this as dividing the body in half, as if someone show an arrow toward it

106
Q

coronal
KOR-oh-nal

A

divides the body along a hypothetical plane from front to back
corona is Latin for crown; this plane divides the body in half from the top of the head down like something putting a crown on the head

107
Q

transverse
tranz-VERS

A

divides the body from top to bottom

108
Q

diagnosis

A

identification of the patient’s problem

109
Q

differential diagnosis

A

a list of possibilities for the patient’s problem (a list of possibilities for the diagnosis)

110
Q

clinic note

A

author: medical professional
@ clinic
purpose: documents a visit
format: SOAP

111
Q

consult note

A

author: physician, usually a specialist
@ clinic or hospital
purpose: provides an expert opinion on a more challenging problem
format: SOAP
can be in the form of a letter to the PCP

112
Q

emergency department note

A

author: ED medical staff
@ emergency department
purpose: documents an ED visit
format: SOAP
the A includes an ED course

113
Q

admission summary note

A

author: hospital medical professional
@ hospital
purpose: documents the admission of a patient to the hospital
format: SO A/P
S,O = very thorough
A = differential diagnosis
P = further testing and care
A + P = problem-based approach

114
Q

discharge summary note

A

author: medical professional
@ hospital
purpose: describes when and why the patient was admitted; documents a longer stay
format: ASOP
starts with A

115
Q

operative report note

A

author: surgeon
purpose: documents a surgery in detail
format: ASOP
starts with A

116
Q

daily hospital note/progress note

A

author: medical professional
@ inpatient health care facility
purpose: documents daily hospital vist
format: SO A/P
S - focuses on how patient’s condition has changed since the previous note
A - sometimes includes a differential diagnosis

117
Q

radiology report note

A

author: radiology
purpose: explains reason for image, how image was performed, what was seen on image, radiologist’s assessment; sometimes a recommendation
format: SOA (sometimes P)

118
Q

pathology report note

A

author: pathology
purpose: provides reason for test, what was seen on the test, and an assessment
format: SOA

119
Q

prescription note

A

author: medical professional
purpose: provides directions for a medication
format: P
1. medicine’s name
2. instructions for patient
3. how much medicine should be given
4. refills, if any
5. health care professional’s signature and whether generic substitution is allowed

120
Q

CCU

A

coronary care unit

121
Q

ECU

A

emergency care unit

122
Q

ER

A

emergency room

123
Q

ED

A

emergency department

124
Q

ICU

A

intensive care unit

125
Q

PICU

A

pediatric intensive care unit

126
Q

NICU

A

neonatal intensive care unit

127
Q

SICU

A

surgical intensive care unit

128
Q

PACU

A

post-anesthesia care unit

129
Q

L&D

A

labor and delivery

130
Q

OR

A

operating room

131
Q

(R)

A

right

132
Q

(L)

A

left

133
Q

(B)

A

bilateral (both sides)

134
Q

VS

A

vital signs

135
Q

T

A

temperature

136
Q

BP

A

blood pressure

137
Q

HR

A

heart rate

138
Q

RR

A

respiratory rate

139
Q

Ht

A

height

140
Q

Wt

A

weight

141
Q

BMI

A

body mass index (measurement of body fat based on height and weight)

142
Q

I/O

A

intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)

143
Q

Dx

A

diagnosis

144
Q

DDx

A

differential diagnosis

145
Q

Tx

A

treatment

146
Q

Rx

A

prescription

147
Q

H&P

A

history and physical

148
Q

Hx

A

history

149
Q

CC

A

chief complaint (main reason for visit)

150
Q

HPI

A

history of present illness (the story of the symptoms)

151
Q

ROS

A

review of systems (anything else not directly related to the chief complaint)

152
Q

PMHx

A

past medical history

153
Q

FHx

A

family history

154
Q

NKDA

A

no known drug allergies

155
Q

PE

A

physical exam

156
Q

Pt

A

patient

157
Q

y/o

A

years old

158
Q

h/o

A

history of

159
Q

PCP

A

primary care provider

160
Q

f/u

A

follow up

161
Q

SOB (SOA)

A

shortness of breath (shortness of air)

162
Q

HEENT

A

head, eyes, ears, nose, and throat

163
Q

PERRLA

A

pupils are equal, round, and reactive to light and accommodation

164
Q

NAD

A

no acute distress (the patient does not display any intense symptoms)

165
Q

CV

A

cardiovascular

166
Q

RRR

A

regular rate and rhythm (description of a normal heart on exam)

167
Q

CTA

A

clear to auscultation (description of normal-sounding lungs)

168
Q

WDWN

A

well developed, well nourished (the patient is growing or has grown appropriately and does not appear to be malnourished)

169
Q

A&O

A

alert and oriented (the patient can answer questions and is aware of what’s going on)

170
Q

WNL

A

within normal limits

171
Q

NOS

A

not otherwise specified

172
Q

NEC

A

not elsewhere classified

173
Q

PO

A

per os (by mouth)

174
Q

NPO

A

nil per os (nothing by mouth)

175
Q

PR

A

per rectum (anal)

176
Q

IM

A

intramuscular

177
Q

SC

A

subcutaneous (under the skin)

178
Q

IV

A

intravenous

179
Q

CVL

A

central venous line

180
Q

PICC

A

peripherally inserted central catheter

181
Q

Sig

A

instructions short for signa, from Latin for “label”

182
Q

BID

A

twice daily

183
Q

TID

A

three times daily

184
Q

Q

A

every x
Q4hr = every 4 hours
Q3 = every 3 days

185
Q

QHS

A

at night

186
Q

AC

A

before meals

187
Q

PC

A

after meals

188
Q

prn

A

as needed

189
Q

ad lib

A

as desired

MED-121 (7 decks)

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