Health Records Flashcards

1
Q

Noncontributory

A

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.

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2
Q

Acute

A

Recently happened. Goes away quickly

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3
Q

Chronic

A

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

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4
Q

Abrupt

A

Occurs suddenly

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5
Q

Progressive

A

Symptoms get worse

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6
Q

Exacerbation

A

Condition gets worse

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7
Q

Febrile

A

Has a fever

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8
Q

Afebrile

A

Doesn’t have a fever

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9
Q

Alert

A

Responsive

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10
Q

Oriented

A

Able to tell you what time or day it is

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11
Q

Percussion

A

Hit and listen for vibrations

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12
Q

Palpitation

A

To touch or feel

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13
Q

Unremarkable

A

Things that you can’t see

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14
Q

Marked

A

Things you can see

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15
Q

Diagnosis

A

Taking information and determining the problem

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16
Q

Differential Diagnosis

A

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

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17
Q

Etiology

A

Cause of the disease

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18
Q

Idiopathic

A

No known cause of the disease

19
Q

Benign

A

Not cancerous

20
Q

Malignant

21
Q

Remission

A

No more symptoms but not sure if cancer free

22
Q

Morbidity

A

How likely we are to get sick

23
Q

Mortality

A

The risk of dying

24
Q

Prognosis

A

The chance of getting better

25
Localized
Stays in a specific area
26
Systemic/ Generalized
Large area or system of the body
27
Pathogen
Something that causes disease
28
Lesion
Diseased tissue
29
Sequelae
Sequel
30
Symptom
What a patient feels
31
SOAP Method
Subjective Objective Assessment Plan
32
Chief complaint
The main reason for the patient's visit
33
History of present illness
The story of the patient's problem
34
Review of systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem
35
Past medical history
Other significant past illnesses, like high blood pressure, asthma, or diabetes
36
Past surgical history
Any of the patient's past surguries
37
Family history
Any significant illnesses that run in the patient's family
38
Social history
A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
39
Clinic note
Anytime a health care professional sees a patient in an office setting, he or she must document the visit
40
Consult note
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
41
Emergency department note
Patient's seen in emergency departments and urgent care clinics are almost always new to the medical staff
42
Admission summary
The assessment, which usually describes the thought process behind a patient's diagnosis and a list of possible causes for the patient's problem
43
Discharge summary
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