Chapter 2 (EMR) Flashcards
Introduction to Health Records
The SOAP Method
S = Subjective
O = Objective
A = Assessment
P = Plan
Subjective
The “S”OAP Method
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
Objective
The S”O”AP Method
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,
Assessment
The SO”A”P Method
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.
Plan
The SOA”P” Method
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.
cranial
KRAY-nee-al
toward the top
proximal
PRAWK-sih-mal
closer in to the center
proximal and approximate come from the same word and mean close
distal
DIS-tal
farther away from the center
distal and distant come from the same word and mean far
caudal
KAWD-al
toward the bottom
from Latin, for tail
inferior
in-FEER-ee-or
below
superior
soo-PEE-ree-or
above
supine
SOO-pain
lying down on back
prone
PROHN
lying down on belly
contralateral
KON-trah-LAT-eh-ral
opposite side
lateral
LAT-er-al
out to the side
think of a quaterback lateraling a football to a running back
medial
MEED-ee-al
toward the middle
like to the median of a highway
ventral/antral/anterior
VEN-tral / AN-tral / an-TEER-ee-or
the front
the word ventral means “stomach”
dorsal/posterior
DOR-sal / pos-TEE-ree-or
the back
a dorsal fin on a shark is on its back
ipsilateral
IP-sih-LAT-eh-ral
same side
unilateral
YOO-nih-LAT-er-al
one side
bilateral
bai-LAT-eh-ral
both sides
dorsum
DOR-sum
the top of the hand or foot
palmar
PAL-mar
the palm of the hand
plantar
PLANT-ar
the sole of the foot
physician
fih-ZISH-un
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)
pediatrician
pee-dee-ah-TRISH-un
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-es-THEE-zee-AWL-oh-jist
a physician with special training in pain sedation and pain control
epidemiologist
EP-ih-DEE-mee-AWL-uh-jist
a specialist in the study of causes and distribution of diseases in populations and the use of this data to enhance public health
physician assistant (PA)
fih-ZISH-un ah-SIS-tant
a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training
nurse practitioner (NP)
NIRS prak-TISH-ih-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 MED-ih-kal tek-NISH-un
a specially trained in the emergency care of a patient before and/or during transport to medical facility
speech therapist
SPEECH THER-ah-pist
specially trained in evaluating and treating problems with speech and/or swallowing
occupational therapist
aw-kyoo-PAY-shuh-nal THER-ah-pist
specially trained in evaluating and treating problems with performing daily activities at home, school, or work
physical therapist
FIZ-ih-kal THER-ah-pist
specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury
respiratory therapist
res-PIR-ah-toh-ree THER-ah-pist
specially trained in 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) / licenced vocational nurse (LVN)
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
MED-ih-kal ah-SIS-tant
trained to carry out basic administrative and clinical tasks under the guidance of a health care provider
pathologist
pah-THAWL-oh-jist
a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
medical laboratory technician
MED-ih-kal LAB-rah-TOR-ee tek-NISH-un
trained in performing laboratory testing on bodily fluids
phlebotomist
fle-BAWT-oh-mist
trained in the removal of blood from the body for diagnostic or therapeutic purposes
radiologist
ray-dee-AWL-oh-just
a physician specially trained in evaluating images of the body to diagnose illness or injury
radiology technician
ray-dee-AWL-oh-jee tek-NISH-un
trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider
ultrasonagrapher
UL-trah-soh-NAWG-rah-fer
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-NISH-un
trained to assist a 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
MED-ih-kal tranz-KRIP-shon-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 high blood pressure, 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
acute
ah-KYOOT
it just started recently or is a sharp, severe symptom
chronic
KRAWN-ik
it has been going on for a while
exacerbation
eks-AS-er-BAY-shun
it is getting worse
abrupt
ah-BRUPT
all of a sudden
febrile
FEH-brail
to have a fever
afebrile
uh-FEB-ril
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-TRIH-byoo-TOR-ee
not related to this specific problem
lethargic
lah-THAR-jik
a decrease in level of consciousness; in medical record, this is generally an indication that the patient is really sick
genetic/hereditary
jen-ET-ik / heh-RED-ih-TER-ee
it runs in the family
alert
ah-LERT
able to answer questions; responsive; interactive
oriented
OR-ee-EN-ted
being aware of who they are, where they are, and the current time; a patient who is aware of all three is “oriented x3”
marked
MARKT
it really stands out
unremarkable
un-ree-MAR-kah-bul
another way of saying normal
auscultation
aw-skul-TAY-shun
to listen
percussion
per-KUSH-un
to hit something and listen to the resulting sound or feeling for the resulting vibration; drums are a percussion instrument
palpation
pal-PAY-shun
to feel
impression
im-PRESH-un
another way saying assessment
diagnosis
DAI-ag-NOH-sis
what the health care professional thinks the patient has
differential diagnosis
DIF-eh-REN-chal-DAI-ag-NOH-sis
a list of conditions the patient may have based on the sympotms exhibited and the results of the exam
benign
beh-NAIN
safe
malignant
mah-LIG-nant
dangerous, a problem
degeneration
dee-JEN-eh-RAY-shun
to be getting worse
remission
rih-MISH-un
to get better or improve; most often use when discussing cancer; remission does not mean cure
idiopathic
ID-ee-oh-PATH-ik
no known specific cause; it just happens
localized
LOH-kal-aized
stays in a certain part of the body
systemic/generalized
sis-TEM-ik / JEN-ral-aized
all over the body (or most of it)
prognosis
prawg-NOH-sis
the chances for things getting better or worse
occult
ah-KULT
hidden
lesion
LEE-zhun
diseased tissue
recurrent
rih-KUR-ent
to have again
sequela
seh-KWEL-eh
a problem resulting from a disease or injury
pending
PEN-ding
waiting for
pathogen
PATH-oh-jen
the organism that causes the problem
morbidity
mor-BID-it-ee
the risk for being sick
mortality
mor-TAL-it-ee
the risk for dying
etiology
EET-ee-AWL-oh-jee
the cause
disposition
dis-poh-ZISH-un
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)
discharge
DIS-charj
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)
palliative
PAL-ee-AH-tiv
treating the symptoms, but not actually getting rid of the cause
observation
OB-zer-VAY-shun
watch, 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
STER-ul
extremely clean, germ-free conditions; especially important during medical procedures and surgery
prophylaxis
proh-fih-LAK-sis
preventative treatment
sagittal
SAJ-ih-tal
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
coronal
KOR-oh-nal
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
transverse
tranz-VERS
divides the body from top to bottom
diagnosis
identification of the patient’s problem
differential diagnosis
a list of possibilities for the patient’s problem (a list of possibilities for the diagnosis)
clinic note
author: medical professional
@ clinic
purpose: documents a visit
format: SOAP
consult note
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
emergency department note
author: ED medical staff
@ emergency department
purpose: documents an ED visit
format: SOAP
the A includes an ED course
admission summary note
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
discharge summary note
author: medical professional
@ hospital
purpose: describes when and why the patient was admitted; documents a longer stay
format: ASOP
starts with A
operative report note
author: surgeon
purpose: documents a surgery in detail
format: ASOP
starts with A
daily hospital note/progress note
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
radiology report note
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)
pathology report note
author: pathology
purpose: provides reason for test, what was seen on the test, and an assessment
format: SOA
prescription note
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
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 care unit
L&D
labor and delivery
OR
operating room
(R)
right
(L)
left
(B)
bilateral (both sides)
VS
vital signs
T
temperature
BP
blood pressure
HR
heart rate
RR
respiratory rate
Ht
height
Wt
weight
BMI
body mass index (measurement of body fat based on height and weight)
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 (main reason for visit)
HPI
history of present illness (the story of the symptoms)
ROS
review of systems (anything else not directly related to the chief complaint)
PMHx
past 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 (SOA)
shortness of breath (shortness of air)
HEENT
head, eyes, ears, nose, and throat
PERRLA
pupils are equal, round, and reactive to light and accommodation
NAD
no acute distress (the patient does not display any intense symptoms)
CV
cardiovascular
RRR
regular rate and rhythm (description of a normal heart on exam)
CTA
clear to auscultation (description of normal-sounding lungs)
WDWN
well developed, well nourished (the patient is growing or has grown appropriately and does not appear to be malnourished)
A&O
alert and oriented (the patient can answer questions and is aware of what’s going on)
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 (anal)
IM
intramuscular
SC
subcutaneous (under the skin)
IV
intravenous
CVL
central venous line
PICC
peripherally inserted central catheter
Sig
instructions short for signa, from Latin for “label”
BID
twice daily
TID
three times daily
Q
every x
Q4hr = every 4 hours
Q3 = every 3 days
QHS
at night
AC
before meals
PC
after meals
prn
as needed
ad lib
as desired
