Unit 2 - Health Records Flashcards
1
Q
SOAP
A
Subjective, Objective, Assessment, Plan
2
Q
acute
A
started recently or sharp severe symptom
3
Q
chronic
A
been going on for a while now
4
Q
exacerbation
A
getting worse
5
Q
abrupt
A
all of a sudden
6
Q
febrile
A
to have fever
7
Q
afrebrile
A
to not have a fever
8
Q
malaise
A
not feeling well
9
Q
progressive
A
more and more each day
10
Q
symptom
A
something a patient feels
11
Q
noncontributory
A
not related to specific problem
12
Q
lethargic
A
decrease level of consciousness
13
Q
genetic/hereditary
A
runs in the family
14
Q
alert
A
able to answer questions; responsive; reactive
15
Q
oriented
A
being aware of who, where and current time
all three is “oriented x3”
16
Q
marked
A
really stands out
17
Q
unremarkable
A
another way of saying normal
18
Q
auscultation
A
to listen
19
Q
percussion
A
to hit and listen to resulting sound or feel for resulting vibration
20
Q
palpation
A
to feel
21
Q
impression
A
another way pf saying assessment
22
Q
diagnosis
A
what health professional thinks the patient has
23
Q
differential diagnosis
A
list of conditions the patient may have eased on symptoms exhibited and results of exam
24
Q
benign
A
safe
25
malignant
dangerous; a problem
26
degeneration
to be getting worse
27
etiology
the cause
28
remission
to get better or improve; does not mean cured
29
idiopathic
no known specific cause; it just happens
30
localized
stays in a certain part of the body
31
systemic/generalized
all over the body
32
morbidity
the risk for dying
33
prognosis
chances for things to get better or worse
34
occult
hidden
35
pathogen
organism causing the problem
36
lesion
diseased tissue
37
recurrent
to have again
38
sequelae
a problem resulting from disease or injury
39
pending
waiting for
40
disposition
what happened to a patient at the end of the visit; often used at the end of ED notes to reference where patient went after the visit (home, ICU, etc)
41
discharge
"unload"
1. to send patient home (unload patient)
2. fluid coming out of a part of the body
42
prophylaxis
preventative treatment
43
palliative
treating the symptoms, but not getting rid of the cause
44
observation
watch, keep an eye on
45
reassurance
to tell patient that the problem id not serious or dangerous
46
supportive care
to treat the symptoms and make patient feel better
47
sterile
extremely clean, germ-free conditions
48
proximal
closer to the center
49
distal
away from the center
50
lateral
out to the side
51
medial
towards the middle
52
ventral/antral/anterior
the front
53
dorsal/posterior
the back
54
cranial
toward the top
55
caudal
towards the bottom
56
superior
above
57
inferior
below
58
prone
lying on the belly
59
supine
lying on the back
60
contralateral
opposite side
61
ipsilateral
same side
62
unilateral
one side
63
bilateral
both sides
64
dorsum
top of hand or foot
65
plantar
sole of the foot
66
palmer
palm of the hand
67
sagittal
divides body in slices right to left
68
coronal
divides body in slices front to back
69
transverse
divides body from top to bottom
70
CCU
coronary care unit
71
ECU
emergency care unit
72
ER
emergency room
73
ED
emergency department
74
ICU
intensive care unit
75
PICU
pediatric intensive care unit
76
NICU
neonatal ICU
77
SICU
surgical ICU
78
PACU
post-anesthesia care unit
79
L&D
Labor and delivery
80
OR
operating room
81
VS
vital signs
82
T
temperature
83
BP
blood pressure
84
HR
heart rate
85
RR
respiratory rate
86
Ht
height
87
Wt
weight
88
BMI
body mass index
89
I/O
intake/output; amount of fluids a patient has taken and produced
90
Dx
diagnosis
91
DDx
differential diagnosis
92
Tx
treatment
93
Rx
prescription
94
H&P
history and physical
95
Hx
history
96
CC
chief complaint
97
HPI
history of present illness
98
ROS
review of symptoms
99
PMHx
past medical history
100
FHx
family history
101
NKDA
no known drug allergies
102
PE
physical exam
103
Pt
patient
104
y/o
years old
105
h/o
history of
106
PCP
primary care physician
107
f/u
follow up
108
SOB
shortness of breath (SOA)
109
HEENT
head, eyes, ears, nose, throat
110
PERRLA
pupils are equal, round, reactive to light and accommodation
111
NAD
no acute distress
112
CV
cardiovascular
113
RRR
regular rate and rhythm
114
CTA
clear to auscultation (normal sounding lungs)
115
WDWN
well developed, well nourished
116
A&O
alert and oriented
117
WNL
within normal limits
118
NOS
not otherwise specified
119
NEC
not elsewhere classified
120
PO
per os (by mouth)
121
NPO
nil per os (nothing by mouth)
122
PR
per rectum (anal)
123
IM
intramuscular
124
SC
subcutaneous (under the skin)
125
IV
intravenous
126
CVL
central venous line
127
PICC
peripherally inserted central catheter
128
Sig
instructions
129
BID
twice daily
130
TID
three times daily
131
Q
every x
| example Q4hr every 4 hours
132
QD
daily
133
QID
four times daily
134
QHS
at night
135
AC
before meals
136
PC
after meals
137
prn
as needed
138
ad lib
as desired
139
Clinic Note
SOAP
medical professional
documents visit
140
Consult Note
SOAP
clinic or hospital
provides expert opinion
141
ED Note
SOAP
ED staff
documents ED visit
142
Admissions Summary
SO A/P
hospital professional
documents admission
143
Discharge Summary
ASOP
medical professional
describes when/why patient was admitted
144
Operative Report
ASOP
surgeon
documents surgery in detail
145
Daily hospital report/Progress Note
SO A/P
medical professional
documents daily hospital visit
146
Radiology Report
SOA
radiologist
explains reason for image, how it was performed, what was seen, assessment, recommendation
147
Pathology Report
SOA
pathologist
provides reason for test, what was seen, assessment
148
Prescription
P
medical professional
provides direct for meds
