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Med Term > Common Charting Terms > Flashcards

Common Charting Terms Flashcards

0
Q

Objective

A

O in SOAPS. Info gathered (lab results, heart rate, blood pressure, etc)

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1
Q

Subjective

A

S in SOAPS. Info the patient describes (symptoms and complaints)

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2
Q

Assessment

A

A in SOAPS. The assessment plan in usually one sentence describing the patients condition

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3
Q

Plan

A

P in SOAPS. The plan for the patient (get a cast, take this medication, etc)

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4
Q

Acute

A

A condition with severe symptoms and a short course

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5
Q

Benign

A

Mild; non cancerous

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6
Q

Chronic

A

A condition that develops slowly and persists over time

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7
Q

Degeneration

A

Gradual, progressive deterioration of body structure or function over time

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8
Q

Diagnosis

A

Physicians determination of the existence of disease based on objective/subjective findings

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9
Q

Etiology

A

Cause of a disease

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10
Q

Exacerbation

A

Increase in severity; to get worse

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11
Q

Febrile

A

Having an elevated temperature

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12
Q

Gross

A

Visible to the naked eye

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13
Q

Idiopathic

A

Lacking a clearly defined cause

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14
Q

Localized

A

Confined to a specific area

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15
Q

Malignant

A

Harmful, cancerous, or invasive

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16
Q

Marked

A

Meaningful, noteworthy, important

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17
Q

Morbidity

A

State or presence of disease

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18
Q

Mortality

A

Death

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19
Q

Prognosis

A

Knowledgeable prediction of the outcome of a disease

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20
Q

Progressive

A

Continuing increase in the severity of signs and symptoms of a disease. Can be good or bad

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21
Q

prophylaxis

A

Measure that prevents

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22
Q

Recurrent

A

Happening repeatedly after a period of inactivity

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23
Q

Systemic

A

Throughout the body

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24
Q

Unremarkable

A

Unimportant, not meaningful

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25
Q

Inhalation

A

Inhaling, breathing in

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26
Q

Oral

A

By word of mouth, spoken rather than written

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27
Q

Rectal

A

Terminal portion if the large intestine

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28
Q

Sublingual

A

Situated or applied under the tongue

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29
Q

Topical

A

Relating or applied directly to a part of the body

30
Q

Transdermal

A

Application of medicine through the skin

31
Q

Parenteral

A

Taken somewhere else in the body than the mouth and alimentary canal

32
Q

A

A

Assessment or analysis

33
Q

ADL

A

Activities of daily living

34
Q

BP

A

Blood pressure

35
Q

CC

A

Chief complaint

36
Q

c/o

A

Complains of (patients description of symptoms)

37
Q

CP

A

Chest pain

38
Q

D/C

A

Discontinue

39
Q

⬇️

A

Decrease or decreasing

40
Q

Dx

A

Diagnosis

41
Q

H & P

A

History and physical

42
Q

Ht

A

Height

43
Q

Hx

A

Personal medical HISTORY

44
Q

ICU

A

Intensive care unit

45
Q

⬆️

A

Increase or increasing

46
Q

IP

A

Inpatient

47
Q
A

Left

48
Q

NKA

A

No known allergies

49
Q

NKDA

A

No known drug allergies

50
Q

O with ➖ through it

A

None

51
Q

OP

A

Outpatient

52
Q

OR

A

Operating room

53
Q

P

A

Pulse

54
Q

PE

A

Physical examination

55
Q

PI

A

Present illness

56
Q

Postop

A

Recovery room

57
Q

Preop

A

Pre-operating area

58
Q

pt

A

Patient

59
Q

Px

A

Physical examination

60
Q

R

A

Respirations

61
Q
A

Right

62
Q

R/O

A

Rule out

63
Q

ROM

A

Range of motion

64
Q

ROS

A

Review of symptoms

65
Q

SOB

A

Shortness of breath

66
Q

S

A

Signs

67
Q

Sx

A

Symptoms

68
Q

T

A

Temperature

69
Q

Tx

A

Treatment

70
Q

VS

A

Vital signs

71
Q

WNL

A

Within normal limits

72
Q

Wt.

A

Weight

73
Q

➖ Over a

A

Before

Med Term (3 decks)

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