Health Records Flashcards
Noncontributory
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.
Acute
Recently happened. Goes away quickly
Chronic
Long lasting. Takes a lot of time to go away if it ever goes away.
Abrupt
Occurs suddenly
Progressive
Symptoms get worse
Exacerbation
Condition gets worse
Febrile
Has a fever
Afebrile
Doesn’t have a fever
Alert
Responsive
Oriented
Able to tell you what time or day it is
Percussion
Hit and listen for vibrations
Palpitation
To touch or feel
Unremarkable
Things that you can’t see
Marked
Things you can see
Diagnosis
Taking information and determining the problem
Differential Diagnosis
Not able to tell what’s wrong but comes up with a conclusion based off the patients symptoms
Etiology
Cause of the disease
Idiopathic
No known cause of the disease
Benign
Not cancerous
Malignant
Cancerous
Remission
No more symptoms but not sure if cancer free
Morbidity
How likely we are to get sick
Mortality
The risk of dying
Prognosis
The chance of getting better
Localized
Stays in a specific area
Systemic/ Generalized
Large area or system of the body
Pathogen
Something that causes disease
Lesion
Diseased tissue
Sequelae
Sequel
Symptom
What a patient feels
SOAP Method
Subjective
Objective
Assessment
Plan
Chief complaint
The main reason for the patient’s visit
History of present illness
The story of the patient’s problem
Review of systems
Description of individual body systems in order to discover any symptoms not directly related to the main problem
Past medical history
Other significant past illnesses, like high blood pressure, asthma, or diabetes
Past surgical history
Any of the patient’s past surguries
Family history
Any significant illnesses that run in the patient’s family
Social history
A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Clinic note
Anytime a health care professional sees a patient in an office setting, he or she must document the visit
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
Emergency department note
Patient’s seen in emergency departments and urgent care clinics are almost always new to the medical staff
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
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
