Common Charting Terms Flashcards
Objective
O in SOAPS. Info gathered (lab results, heart rate, blood pressure, etc)
Subjective
S in SOAPS. Info the patient describes (symptoms and complaints)
Assessment
A in SOAPS. The assessment plan in usually one sentence describing the patients condition
Plan
P in SOAPS. The plan for the patient (get a cast, take this medication, etc)
Acute
A condition with severe symptoms and a short course
Benign
Mild; non cancerous
Chronic
A condition that develops slowly and persists over time
Degeneration
Gradual, progressive deterioration of body structure or function over time
Diagnosis
Physicians determination of the existence of disease based on objective/subjective findings
Etiology
Cause of a disease
Exacerbation
Increase in severity; to get worse
Febrile
Having an elevated temperature
Gross
Visible to the naked eye
Idiopathic
Lacking a clearly defined cause
Localized
Confined to a specific area
Malignant
Harmful, cancerous, or invasive
Marked
Meaningful, noteworthy, important
Morbidity
State or presence of disease
Mortality
Death
Prognosis
Knowledgeable prediction of the outcome of a disease
Progressive
Continuing increase in the severity of signs and symptoms of a disease. Can be good or bad
prophylaxis
Measure that prevents
Recurrent
Happening repeatedly after a period of inactivity
Systemic
Throughout the body
Unremarkable
Unimportant, not meaningful
Inhalation
Inhaling, breathing in
Oral
By word of mouth, spoken rather than written
Rectal
Terminal portion if the large intestine
Sublingual
Situated or applied under the tongue
Topical
Relating or applied directly to a part of the body
Transdermal
Application of medicine through the skin
Parenteral
Taken somewhere else in the body than the mouth and alimentary canal
A
Assessment or analysis
ADL
Activities of daily living
BP
Blood pressure
CC
Chief complaint
c/o
Complains of (patients description of symptoms)
CP
Chest pain
D/C
Discontinue
⬇️
Decrease or decreasing
Dx
Diagnosis
H & P
History and physical
Ht
Height
Hx
Personal medical HISTORY
ICU
Intensive care unit
⬆️
Increase or increasing
IP
Inpatient
Left
NKA
No known allergies
NKDA
No known drug allergies
O with ➖ through it
None
OP
Outpatient
OR
Operating room
P
Pulse
PE
Physical examination
PI
Present illness
Postop
Recovery room
Preop
Pre-operating area
pt
Patient
Px
Physical examination
R
Respirations
Right
R/O
Rule out
ROM
Range of motion
ROS
Review of symptoms
SOB
Shortness of breath
S
Signs
Sx
Symptoms
T
Temperature
Tx
Treatment
VS
Vital signs
WNL
Within normal limits
Wt.
Weight
➖ Over a
Before