Health Records Flashcards
discharge summary
describes when and why the patient was admitted, documents a longer stay, ASOP
operative report
documents a surgery in detail, ASOP
daily hospital note/progress note
documents daily hospital visit, SO A/P
radiology report
explains reason for image, how image was performed, what was seen on image, radiologist’s assessment, sometimes a recommendation, SOA
pathology report
provides reasons for test, what was seen on the test, assessment, SOA
prescription
provides directions for a medication, P
abrupt
s - all of a sudden
acute
s - just started recently, sharp/severe symptom
afebrile
s - to not have a fever
chronic
s - has been going on for a while
exacerbation
s - getting worse
febrile
s - to have a fever
genetic, hereditary
s - runs in the family
lethargic
s - decrease in level of consciousness
malaise
s - not feeling well
noncontributory
s - not related to this specific problem
progressive
s - more and more each day
symptom
s - something a patient feels
alert
o - able to answer questions, responsive, interactive
auscultation
o - to listen
marked
o - it really stands out
oriented
o - being aware of who one is, where one is, and the current time
palpation
o - to feel
percussion
o - to hit something and listen to the resulting sound or feel resulting vibration
unremarkable
o - normal
impression
a - assessment
diagnosis
a - what the healthcare professional thinks the patient has
differential diagnosis
a - a list of conditions the patient may have based on symptoms exhibited and results of exam
benign
a - safe
malignant
a - dangerous
degeneration
a - getting worse
etiology
a - the cause
remission
a - to get better or improve
idiopathic
a - no known specific cause
localized
a - stays in a certain part of the body
systematic/generalized
a - all over the body
morbidity
a - the risk for being sick
mortality
a - the risk for dying
prognosis
a - the chances for things getting better or worse
occult
a - hidden
pathogen
a - the organism that causes the problem
lesion
a - diseased tissue
recurrent
a - to have again
sequelae
a - a problem resulting from a disease or injury
pending
a - waiting for
discharge
p - to send home, or fluid coming out a part of the body
disposition
p - what happened to the patient at the end of the visit, often the end of ED notes
observation
p - watch, keep an eye on
palliative
p - treating the symptoms but not actually getting rid of the cause
prophylaxis
p - preventative treatment
reassurance
p - to tell the patient that the problem is not serious or dangerous
sterile
p - extremely clean, germ-free conditions
supportive care
p - to treat the symptoms and make the patient feel better
distal
farther away from the center
proximal
closer in to the center
lateral
side
medial
middle
dorsal, posterior
back
ventral, antral, anterior
front
caudal
toward the bottom (skull)
cranial
toward the top (skull)
inferior
below
superior
above
prone
lying down on belly
supine
lying down on back
contralateral
opposite side
ipsilateral
same side
bilateral
both sides
unilateral
one side
dorsum
top of hand or foot
plantar
sole of foot
palmar
palm of hand
coronal
crown, divides body front and back
sagittal
arrow, divides body left and right
transverse
divides body top and bottom
what the patient says (blue)
s - subjective
physical exam, what tests reveal (red)
o - objective
analysis of subjective and objective info, diagnosis and identification (yellow)
a - assessment
course of action, treatment (green)
p - plan
main reason for patient visit
chief complaint
story of the problem
history of present illness
description of individual body systems to discover problems not directly related to main problem
review of systems
significant past illnesses
past medical history
past surgeries
past surgical history
illnesses that run in the family
family history
record of habits that impact health
social history
documents a visit, SOAP, new patients includes more history, streamlined note for repeat patients
clinic note
provides an expert opinion on a more challenging problem, SOAP, can be in the form of a letter to the PCP
consult note
documents an emergency department visit, SOAP, A includes the ED course
emergency department note
documents the admission of a patient to the hospital, SO A/P
admission summary
describes when and why the patient was admitted, documents a longer stay, ASOP
discharge summary
documents a surgery in detail, ASOP
operative report
documents daily hospital visit, SO A/P
daily hospital note/progress note
explains reason for image, how image was performed, what was seen on image, radiologist’s assessment, sometimes a recommendation, SOA
radiology report
provides reasons for test, what was seen on the test, assessment, SOA
pathology report
provides directions for a medication, P
prescription
s - all of a sudden
abrupt
s - just started recently, sharp/severe symptom
acute
s - to not have a fever
afebrile
s - has been going on for a while
chronic
s - getting worse
exacerbation
s - to have a fever
febrile
s - runs in the family
genetic, hereditary
s - decrease in level of consciousness
lethargic
s - not feeling well
malaise
s - not related to this specific problem
noncontributory
s - more and more each day
progressive
s - something a patient feels
symptom
o - able to answer questions, responsive, interactive
alert
o - to listen
auscultation
o - it really stands out
marked
o - being aware of who one is, where one is, and the current time
oriented
o - to feel
palpation
o - to hit something and listen to the resulting sound or feel resulting vibration
percussion
o - normal
unremarkable
a - assessment
impression
a - what the healthcare professional thinks the patient has
diagnosis
a - a list of conditions the patient may have based on symptoms exhibited and results of exam
differential diagnosis
a - safe
benign
a - dangerous
malignant
a - getting worse
degeneration
a - the cause
etiology
a - to get better or improve
remission
a - no known specific cause
idiopathic
a - stays in a certain part of the body
localized
a - all over the body
systematic/generalized
a - the risk for being sick
morbidity
a - the risk for dying
mortality
a - the chances for things getting better or worse
prognosis
a - hidden
occult
a - the organism that causes the problem
pathogen
a - diseased tissue
lesion
a - to have again
recurrent
a - a problem resulting from a disease or injury
sequelae
a - waiting for
pending
p - to send home, or fluid coming out a part of the body
discharge
p - what happened to the patient at the end of the visit, often the end of ED notes
disposition
p - watch, keep an eye on
observation
p - treating the symptoms but not actually getting rid of the cause
palliative
p - preventative treatment
prophylaxis
p - to tell the patient that the problem is not serious or dangerous
reassurance
p - extremely clean, germ-free conditions
sterile
p - to treat the symptoms and make the patient feel better
supportive care
farther away from the center
distal
closer in to the center
proximal
side
lateral
middle
medial
back
dorsal, posterior
front
ventral, antral, anterior
toward the bottom (skull)
caudal
toward the top (skull)
cranial
below
inferior
above
superior
lying down on belly
prone
lying down on back
supine
opposite side
contralateral
same side
ipsilateral
both sides
bilateral
one side
unilateral
top of hand or foot
dorsum
sole of foot
plantar
palm of hand
palmar
crown, divides body front and back
coronal
arrow, divides body left and right
sagittal
divides body top and bottom
transverse
