Health Records

Question 1

Noncontributory

Answer 1

Symptom that has nothing to do with disease.

ex: going to the doctor because you have the flu but finding that you broke your leg.

Question 2

Acute

Answer 2

Recently happened. Goes away quickly

Question 3

Chronic

Answer 3

Long lasting. Takes a lot of time to go away if it ever goes away.

Question 4

Abrupt

Answer 4

Occurs suddenly

Question 5

Progressive

Answer 5

Symptoms get worse

Question 6

Exacerbation

Answer 6

Condition gets worse

Question 7

Febrile

Answer 7

Has a fever

Question 8

Afebrile

Answer 8

Doesn’t have a fever

Question 9

Alert

Answer 9

Responsive

Question 10

Oriented

Answer 10

Able to tell you what time or day it is

Question 11

Percussion

Answer 11

Hit and listen for vibrations

Question 12

Palpitation

Answer 12

To touch or feel

Question 13

Unremarkable

Answer 13

Things that you can’t see

Question 14

Marked

Answer 14

Things you can see

Question 15

Diagnosis

Answer 15

Taking information and determining the problem

Question 16

Differential Diagnosis

Answer 16

Not able to tell what’s wrong but comes up with a conclusion based off the patients symptoms

Question 17

Etiology

Answer 17

Cause of the disease

Question 18

Idiopathic

Answer 18

No known cause of the disease

Question 19

Benign

Answer 19

Not cancerous

Question 20

Malignant

Answer 20

Cancerous

Question 21

Remission

Answer 21

No more symptoms but not sure if cancer free

Question 22

Morbidity

Answer 22

How likely we are to get sick

Question 23

Mortality

Answer 23

The risk of dying

Question 24

Prognosis

Answer 24

The chance of getting better

Question 25

Localized

Answer 25

Stays in a specific area

Question 26

Systemic/ Generalized

Answer 26

Large area or system of the body

Question 27

Pathogen

Answer 27

Something that causes disease

Question 28

Lesion

Answer 28

Diseased tissue

Question 29

Sequelae

Answer 29

Sequel

Question 30

Symptom

Answer 30

What a patient feels

Question 31

SOAP Method

Answer 31

Subjective
Objective
Assessment
Plan

Question 32

Chief complaint

Answer 32

The main reason for the patient’s visit

Question 33

History of present illness

Answer 33

The story of the patient’s problem

Question 34

Review of systems

Answer 34

Description of individual body systems in order to discover any symptoms not directly related to the main problem

Question 35

Past medical history

Answer 35

Other significant past illnesses, like high blood pressure, asthma, or diabetes

Question 36

Past surgical history

Answer 36

Any of the patient’s past surguries

Question 37

Family history

Answer 37

Any significant illnesses that run in the patient’s family

Question 38

Social history

Answer 38

A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

Question 39

Clinic note

Answer 39

Anytime a health care professional sees a patient in an office setting, he or she must document the visit

Question 40

Consult note

Answer 40

The most common format is a note similar to the clinic note, however, sometimes the specialist may prefer to write the note in the form of a letter to the primary care provider

Question 41

Emergency department note

Answer 41

Patient’s seen in emergency departments and urgent care clinics are almost always new to the medical staff

Question 42

Admission summary

Answer 42

The assessment, which usually describes the thought process behind a patient’s diagnosis and a list of possible causes for the patient’s problem

Question 43

Discharge summary

Answer 43

Details when and why a patient was admitted, how the patient felt when admitted, what happened during the patient’s stay in the hospital, and what kind of follow-up the patient will have