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Medical Terminology > Health Records > Flashcards

Health Records Flashcards

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USMLE® Step 1 flashcards
1
Q

discharge summary

A

describes when and why the patient was admitted, documents a longer stay, ASOP

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2
Q

operative report

A

documents a surgery in detail, ASOP

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3
Q

daily hospital note/progress note

A

documents daily hospital visit, SO A/P

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4
Q

radiology report

A

explains reason for image, how image was performed, what was seen on image, radiologist’s assessment, sometimes a recommendation, SOA

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5
Q

pathology report

A

provides reasons for test, what was seen on the test, assessment, SOA

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6
Q

prescription

A

provides directions for a medication, P

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7
Q

abrupt

A

s - all of a sudden

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8
Q

acute

A

s - just started recently, sharp/severe symptom

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9
Q

afebrile

A

s - to not have a fever

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10
Q

chronic

A

s - has been going on for a while

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11
Q

exacerbation

A

s - getting worse

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12
Q

febrile

A

s - to have a fever

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13
Q

genetic, hereditary

A

s - runs in the family

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14
Q

lethargic

A

s - decrease in level of consciousness

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15
Q

malaise

A

s - not feeling well

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16
Q

noncontributory

A

s - not related to this specific problem

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17
Q

progressive

A

s - more and more each day

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18
Q

symptom

A

s - something a patient feels

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19
Q

alert

A

o - able to answer questions, responsive, interactive

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20
Q

auscultation

A

o - to listen

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21
Q

marked

A

o - it really stands out

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22
Q

oriented

A

o - being aware of who one is, where one is, and the current time

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23
Q

palpation

A

o - to feel

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24
Q

percussion

A

o - to hit something and listen to the resulting sound or feel resulting vibration

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25
Q

unremarkable

A

o - normal

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26
Q

impression

A

a - assessment

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27
Q

diagnosis

A

a - what the healthcare professional thinks the patient has

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28
Q

differential diagnosis

A

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

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29
Q

benign

A

a - safe

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30
Q

malignant

A

a - dangerous

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31
Q

degeneration

A

a - getting worse

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32
Q

etiology

A

a - the cause

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33
Q

remission

A

a - to get better or improve

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34
Q

idiopathic

A

a - no known specific cause

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35
Q

localized

A

a - stays in a certain part of the body

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36
Q

systematic/generalized

A

a - all over the body

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37
Q

morbidity

A

a - the risk for being sick

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38
Q

mortality

A

a - the risk for dying

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39
Q

prognosis

A

a - the chances for things getting better or worse

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40
Q

occult

A

a - hidden

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41
Q

pathogen

A

a - the organism that causes the problem

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42
Q

lesion

A

a - diseased tissue

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43
Q

recurrent

A

a - to have again

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44
Q

sequelae

A

a - a problem resulting from a disease or injury

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45
Q

pending

A

a - waiting for

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46
Q

discharge

A

p - to send home, or fluid coming out a part of the body

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47
Q

disposition

A

p - what happened to the patient at the end of the visit, often the end of ED notes

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48
Q

observation

A

p - watch, keep an eye on

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49
Q

palliative

A

p - treating the symptoms but not actually getting rid of the cause

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50
Q

prophylaxis

A

p - preventative treatment

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51
Q

reassurance

A

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

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52
Q

sterile

A

p - extremely clean, germ-free conditions

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53
Q

supportive care

A

p - to treat the symptoms and make the patient feel better

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54
Q

distal

A

farther away from the center

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55
Q

proximal

A

closer in to the center

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56
Q

lateral

A

side

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57
Q

medial

A

middle

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58
Q

dorsal, posterior

A

back

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59
Q

ventral, antral, anterior

A

front

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60
Q

caudal

A

toward the bottom (skull)

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61
Q

cranial

A

toward the top (skull)

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62
Q

inferior

A

below

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63
Q

superior

A

above

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64
Q

prone

A

lying down on belly

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65
Q

supine

A

lying down on back

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66
Q

contralateral

A

opposite side

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67
Q

ipsilateral

A

same side

68
Q

bilateral

A

both sides

69
Q

unilateral

A

one side

70
Q

dorsum

A

top of hand or foot

71
Q

plantar

A

sole of foot

72
Q

palmar

A

palm of hand

73
Q

coronal

A

crown, divides body front and back

74
Q

sagittal

A

arrow, divides body left and right

75
Q

transverse

A

divides body top and bottom

76
Q

what the patient says (blue)

A

s - subjective

77
Q

physical exam, what tests reveal (red)

A

o - objective

78
Q

analysis of subjective and objective info, diagnosis and identification (yellow)

A

a - assessment

79
Q

course of action, treatment (green)

A

p - plan

80
Q

main reason for patient visit

A

chief complaint

81
Q

story of the problem

A

history of present illness

82
Q

description of individual body systems to discover problems not directly related to main problem

A

review of systems

83
Q

significant past illnesses

A

past medical history

84
Q

past surgeries

A

past surgical history

85
Q

illnesses that run in the family

A

family history

86
Q

record of habits that impact health

A

social history

87
Q

documents a visit, SOAP, new patients includes more history, streamlined note for repeat patients

A

clinic note

88
Q

provides an expert opinion on a more challenging problem, SOAP, can be in the form of a letter to the PCP

A

consult note

89
Q

documents an emergency department visit, SOAP, A includes the ED course

A

emergency department note

90
Q

documents the admission of a patient to the hospital, SO A/P

A

admission summary

91
Q

describes when and why the patient was admitted, documents a longer stay, ASOP

A

discharge summary

92
Q

documents a surgery in detail, ASOP

A

operative report

93
Q

documents daily hospital visit, SO A/P

A

daily hospital note/progress note

94
Q

explains reason for image, how image was performed, what was seen on image, radiologist’s assessment, sometimes a recommendation, SOA

A

radiology report

95
Q

provides reasons for test, what was seen on the test, assessment, SOA

A

pathology report

96
Q

provides directions for a medication, P

A

prescription

97
Q

s - all of a sudden

A

abrupt

98
Q

s - just started recently, sharp/severe symptom

A

acute

99
Q

s - to not have a fever

A

afebrile

100
Q

s - has been going on for a while

A

chronic

101
Q

s - getting worse

A

exacerbation

102
Q

s - to have a fever

A

febrile

103
Q

s - runs in the family

A

genetic, hereditary

104
Q

s - decrease in level of consciousness

A

lethargic

105
Q

s - not feeling well

A

malaise

106
Q

s - not related to this specific problem

A

noncontributory

107
Q

s - more and more each day

A

progressive

108
Q

s - something a patient feels

A

symptom

109
Q

o - able to answer questions, responsive, interactive

A

alert

110
Q

o - to listen

A

auscultation

111
Q

o - it really stands out

A

marked

112
Q

o - being aware of who one is, where one is, and the current time

A

oriented

113
Q

o - to feel

A

palpation

114
Q

o - to hit something and listen to the resulting sound or feel resulting vibration

A

percussion

115
Q

o - normal

A

unremarkable

116
Q

a - assessment

A

impression

117
Q

a - what the healthcare professional thinks the patient has

A

diagnosis

118
Q

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

A

differential diagnosis

119
Q

a - safe

A

benign

120
Q

a - dangerous

A

malignant

121
Q

a - getting worse

A

degeneration

122
Q

a - the cause

A

etiology

123
Q

a - to get better or improve

A

remission

124
Q

a - no known specific cause

A

idiopathic

125
Q

a - stays in a certain part of the body

A

localized

126
Q

a - all over the body

A

systematic/generalized

127
Q

a - the risk for being sick

A

morbidity

128
Q

a - the risk for dying

A

mortality

129
Q

a - the chances for things getting better or worse

A

prognosis

130
Q

a - hidden

A

occult

131
Q

a - the organism that causes the problem

A

pathogen

132
Q

a - diseased tissue

A

lesion

133
Q

a - to have again

A

recurrent

134
Q

a - a problem resulting from a disease or injury

A

sequelae

135
Q

a - waiting for

A

pending

136
Q

p - to send home, or fluid coming out a part of the body

A

discharge

137
Q

p - what happened to the patient at the end of the visit, often the end of ED notes

A

disposition

138
Q

p - watch, keep an eye on

A

observation

139
Q

p - treating the symptoms but not actually getting rid of the cause

A

palliative

140
Q

p - preventative treatment

A

prophylaxis

141
Q

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

A

reassurance

142
Q

p - extremely clean, germ-free conditions

A

sterile

143
Q

p - to treat the symptoms and make the patient feel better

A

supportive care

144
Q

farther away from the center

A

distal

145
Q

closer in to the center

A

proximal

146
Q

side

A

lateral

147
Q

middle

A

medial

148
Q

back

A

dorsal, posterior

149
Q

front

A

ventral, antral, anterior

150
Q

toward the bottom (skull)

A

caudal

151
Q

toward the top (skull)

A

cranial

152
Q

below

A

inferior

153
Q

above

A

superior

154
Q

lying down on belly

A

prone

155
Q

lying down on back

A

supine

156
Q

opposite side

A

contralateral

157
Q

same side

A

ipsilateral

158
Q

both sides

A

bilateral

159
Q

one side

A

unilateral

160
Q

top of hand or foot

A

dorsum

161
Q

sole of foot

A

plantar

162
Q

palm of hand

A

palmar

163
Q

crown, divides body front and back

A

coronal

164
Q

arrow, divides body left and right

A

sagittal

165
Q

divides body top and bottom

A

transverse

Medical Terminology (10 decks)

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