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NURS 105 - Medical Terminology > Ch. 2: Intro to Health Records > Flashcards

Ch. 2: Intro to Health Records Flashcards

1
Q

What does SOAP stand for?

A

subjective
objective
assessment
plan

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2
Q

How a patient experiences and personally describes his or her problem, as well as personal and family medical histories.

A

subjective

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3
Q

Data comprised of the physical exam, lab findings, and imaging studies.

A

objective

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4
Q

A logical analysis (identify a problem, or a list of possibilities for the diagnosis).

A

assessment

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5
Q

A course of action consistent with an assessment.

A

plan

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6
Q

acute

A

ah-KYOOT

the problem just started recently, or is a sharp, severe symptom

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7
Q

chronic

A

KRaH-nik

the problem has been going on for a while now

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8
Q

exacerbation

A

ex-SAS-er-BAY-shun

the problem is getting worse

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9
Q

abrupt

A

ah-BRUPT

all of a sudden

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10
Q

febrile

A

FEH-brail

to have a fever

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11
Q

afebrile

A

AY-FEH-brail

to not have a fever

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12
Q

malaise

A

mah-LAYZ

not feeling well

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13
Q

progressive

A

proh-GREH-siv

more and more each day

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14
Q

symptom

A

SIM-tom

something a patient feels

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15
Q

noncontributory

A

NON-kon-TRIB-yoo-TOH-ree

not related to this specific problem

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16
Q

lethargic

A

lah-THAR-jik
a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick

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17
Q

genetic

hereditary

A

jih-NEH-tik
hah-REH-dih-TEH-ree
a problem runs in the family

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18
Q

alert

A

ah-LERT

able to answer questions; responsive; interactive

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19
Q

oriented

A

OR-ee-EN-ted
being aware of who he or she is where he or she is, and the current time; a patient who is aware of all three is “oriented x3”

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20
Q

marked

A

MARKT

something really stands out

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21
Q

unremarkable

A

un-ree-MARK-ah-bul

another way of saying normal

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22
Q

auscultation

A

aws-kul-TAY-shun

to listen

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23
Q

percussion

A

per-KUH-shun

to hit something and listen to the resulting sound or feel for the resulting vibration

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24
Q

palpation

A

pal-PAY-shun

to feel

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25
Q

impression

A

im-PREH-shun

another way of saying assessment

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26
Q

diagnosis

A

DAI-ag-NOH-sis

what the heath care professional thinks the patient has

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27
Q

differential diagnosis

A

dih-ger-EN-shal DAI-ag-NOH-sis

a list of conditions the patient may have based on the symptoms exhibited and the results of the exam

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28
Q

benign

A

beh-NAIN

safe

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29
Q

malignant

A

mah-LIG-nant

dangerous; a problem

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30
Q

degeneration

A

dee-jen-er-AY-shun

to be getting worse

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31
Q

etiology

A

eh-tee-AW-loh-jee

the cause

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32
Q

remission

A

reh-MIH-shun

to get better or improve; most often used when discussion cancer, remission does not mean cure

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33
Q

idiopathic

A

ih-dee-oh-PA-thik

no known specific cause, it just happens

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34
Q

localized

A

LOH-kah-LAIZD

stays in a certain part of the body

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35
Q

systemic

generalized

A

sih-STEM-ik
jen-er-ah-LAIZD
all over the body (or most of it)

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36
Q

morbidity

A

mor-BID-ih-tee

the risk for being sick

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37
Q

mortality

A

mor-TA-lih-tee

the risk for dying

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38
Q

prognosis

A

prawg-NOH-sis

the chances for things getting better or worse

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39
Q

occult

A

ah-KULT

hidden

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40
Q

pathogen

A

PATH-oh-jin

the organism that causes the problem

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41
Q

lesion

A

LEE-shun

diseased tissue

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42
Q

recurrent

A

ree-KUR-ent

to have again

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43
Q

sequelae

A

seh-KWEL-ah

a problem resulting from a disease or injury

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44
Q

pending

A

PEN-ding

waiting for

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45
Q

disposition

A

dis-poh-ZIH-shun
what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU normal hospital bed, etc)

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46
Q

discharge

A

DIS-charj
literally, to unload
1. to send home
2. fluid coming out of a part of the body

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47
Q

prophylaxis

A

PROH-fuh-LAK-sis

preventative treatment

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48
Q

palliative

A

PA-lee-ah-tiv

treating the symptoms, but not actually getting rid of the cause

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49
Q

observation

A

OB-zer-VAY-shun

to watch or keep an eye on

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50
Q

reassurance

A

ree-ah-SHUR-ants

to tell the patient that the problem is not serious or dangerous

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51
Q

supportive care

A

suh-POR-tiv kehr

to treat the symptoms and make the patient feel better

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52
Q

sterile

A

STEH-ril

extremely clean, germ-free conditions; especially important during medical procedures and surgery

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53
Q

proximal

A

PRAWK-sih-mal
closer in to the center
proximal and approximate come from the same word and mean close

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54
Q

distal

A

DIH-stal
farther away from the center
distal and distant come from the same word and mean far

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55
Q

lateral

A

LA-ter-al
out to the side
think of a quarterback lateraling a football to a running back

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56
Q

medial

A

MEE-dee-al
toward the middle
like the median of a highway

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57
Q

ventral
antral
anterior

A 
VEN-tral
AN-tral
an-TIH-ree-or
the front
the word ventral means "stomach"
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58
Q

dorsal

posterior

A

DOR-sal
pohs-TEER-ee-or
the back
a dorsal fin on a shark is on its back

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59
Q

cranial

A

KRAY-nee-al

toward the top

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60
Q

caudal

A

KOW-dal
toward the bottom
from Latin for tail

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61
Q

superior

A

soo-PIH-ree-or

above

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62
Q

inferior

A

in-FIH-ree-or

below

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63
Q

prone

A

PROHN

lying down on belly

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64
Q

supine

A

SOO-pain

lying down on back

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65
Q

contralateral

A

KON-tra-LA-ter-al

opposite side

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66
Q

ipsilateral

A

IP-sih-LA-ter-al

same side

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67
Q

unilater

A

YOO-nih-LA-ter-al

one side

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68
Q

bilateral

A

BAI-LA-ter-al

both sides

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69
Q

dorsum

A

DOR-sum

the top of the hand or foot

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70
Q

plantar

A

PLAN-tar

the sole of the foot

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71
Q

palmar

A

PAL-mar

the palm of the hand

72
Q

sagittal

A

SA-jih-tal
divides the body in right and left slices
sagitta is Latin for arrow; think of this as dividing the body in half, as if someone shot an arrow through it

73
Q

coronal (frontal)

A

kah-ROH-nal
divides the body in front and back slicces
corona is Latin for crown; this plane divides the body in half from the top of the head down

74
Q

transverse

A

tranz-VERS

divides the body from top to bottom

75
Q

physician

A

fuh-ZIH-shun

a skilled health care provider who attended and graduated medical school (MD medical doctor and DO doctor of osteopathy)

76
Q

pediatrician

A

PEE-dee-ah-TRIH-shun

a physician with special training in caring for children

77
Q

surgeon

A

SIR-jen

a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure

78
Q

anesthesiologist

A

AN-ehs-THEE-zee-AWloh-jist

a physician with special training in pain sedation and pain control

79
Q

physician assistant (PA)

A

fuh-ZIH-shun as-SIS-tant

a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training

80
Q

nurse practitioner (NP)

A

NIRS prak-TIH-shuh-ner
a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician

81
Q

emergency medical technician (EMT)

A

eh-MIR-jen-see MEH-dih-kal tek-NIH-shun

specially trained in the emergency care of a patient before and/or during transport to medical facility

82
Q

speech therapist

A

SPEECH THEH-rah-pist

specially trained in evaluating and treating problems with speech and/or swallowing

83
Q

occupational therapist

A

aw-kyoo-PAY-shuh-nal THEH-rah-pist

specially trained in evaluation and treating problems with performing daily activities at home, school, or work

84
Q

physical therapist

A

FIH-sih-kal THEH-rah-pist

specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury

85
Q

respiratory therapist

A

reh-sprah-TOR-ee THEH-rah-pist

specially trained in evaluating and treating patient’s respiratory issues under the guidance of a health care provider

86
Q

dietician

A

dai-ah-TIH-shun

specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan

87
Q

licensed practical nurse (LPN)

licensed vocational nurse (LVN)

A

LAI-senzd PRaK-tih-kal NIRS
LAI-senzd voh-KAY-shun-al NIRS
trained and certified to provide basic care to a patient

88
Q

registered nurse (RN)

A

REH-jis-terd NIRS
an advanced level nurse who has completed an associate’s or bachelor’s degree; often assists with patient care planning and patient education

89
Q

medical assistant

A

MEH-di-kal ah-SIS-tant

trained to carry out basic administrative and clinical tasks under the guidance of a health care provider

90
Q

pathologist

A

pah-THAW-loh-jist

a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine

91
Q

medical laboratory technician

A

med-DIH-kal LAH-broh-tor-ee tek-NIH-shun

trained in performing laboratory testing on bodily fluids

92
Q

phlebotomist

A

fleh-BOH-tow-mist

trained in the removal of blood from the body for diagnostic or therapeutic purposes

93
Q

radiologist

A

ray-dee-AW-loh-jist

a physician specially trained in evaluating images of the body to diagnose illness or injury

94
Q

radiology technician

A

ray-dee-AW-loh-jee tek-NIH-shun

trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider

95
Q

ultrasonographer

A

ul-trah-saw-NAW-grah-fir

trained in performing ultrasound imaging on a patient

96
Q

pharmacist

A

FAR-mah-sist

trained and licensed in preparing and dispensing medicine

97
Q

pharmacy technician

A

FAR-mah-see tek-NIH-shun

trained to assist pharmacist with pharmacy-related tasks

98
Q

patient service coordinator

A

PAY-shent SIR-vis coh-OR-dih-nay-tor

handles administrative tasks and coordinates patient care

99
Q

medical transcriptionist

A

MEH-dih-kal tran-SKRIP-shun-ist

trained in converting the voice-recorded dictations of health care providers into text format

100
Q

chief complaint

A

the main reason for the patient’s visit

101
Q

history of present illness

A

the story of the patient’s problem

102
Q

review of systems

A

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

103
Q

past medical history

A

other significant past illnesses, like HBP, asthma, or diabetes

104
Q

past surgical history

A

any of the patient’s past surgeries

105
Q

family history

A

any significant illnesses that run in the patient’s family

106
Q

social history

A

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

107
Q

CCU

A

coronary care unit

108
Q

ECU

A

emergency care unit

109
Q

ER

A

emergency room

110
Q

ED

A

emergency department

111
Q

ICU

A

intensive care unit

112
Q

PICU

A

pediatric intensive care unit

113
Q

NICU

A

neonatal intensive care unit

114
Q

SICU

A

surgical intensive care unit

115
Q

PACU

A

post-anesthesia intensive care unit

116
Q

L&D

A

labor and delivery

117
Q

OR

A

operating room

118
Q

post-op

A

after surgery

119
Q

pre-op

A

before surgery

120
Q

VS

A

vital signs

121
Q

T

A

temperature

122
Q

BP

A

blood pressure

123
Q

HR

A

heart rate

124
Q

RR

A

respiratory rate

125
Q

Ht

A

height

126
Q

Wt

A

weight

127
Q

BMI

A

body mass index

128
Q

I/O

A

intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)

129
Q

Dx

A

diagnosis

130
Q

DDx

A

differential diagnosis

131
Q

Tx

A

treatment

132
Q

Rx

A

prescription

133
Q

H&P

A

history and physical

134
Q

Hx

A

history

135
Q

CC

A

chief complaint

136
Q

HPI

A

history of present illness

137
Q

ROS

A

review of systems

138
Q

PMHx

A

present medical history

139
Q

FHx

A

family history

140
Q

NKDA

A

no known drug allergies

141
Q

PE

A

physical exam

142
Q

Pt

A

patient

143
Q

y/o

A

years old

144
Q

h/o

A

history of

145
Q

PCP

A

primary care provider

146
Q

f/u

A

follow up

147
Q

SOB

A

shortness of breath or SOA shortness of air

148
Q

HEENT

A

head, eyes, ears, nose, and throat

149
Q

PERRLA

A

pupils equal, round, reactive to light and accommodation

150
Q

NAD

A

no acute distress

151
Q

CV

A

cardiovascualr

152
Q

RRR

A

regular rate and rhythm

153
Q

CTA

A

clear to auscultation

154
Q

WDWN

A

well developed, well nourished

155
Q

A&O

A

alert and oriented

156
Q

WNL

A

within normal limits

157
Q

NOS

A

not otherwise specified

158
Q

NEC

A

not elsewhere classified

159
Q

PO

A

per os (by mouth)

160
Q

NPO

A

nil per os (nothing by mouth)

161
Q

PR

A

per rectum

162
Q

IM

A

intramuscular

163
Q

SC

A

subcutaneous

164
Q

IV

A

intravenous

165
Q

CVL

A

central venous line

166
Q

PICC

A

peripherally inserted central catheter

167
Q

Sig

A

instructions

168
Q

BID

A

twice daily

169
Q

TID

A

three times daily

170
Q

Q

A

every x

171
Q

QD

A

daily

172
Q

QID

A

four times daily

173
Q

QHS

A

at night

174
Q

AC

A

before meals

175
Q

PC

A

after meals

176
Q

prn

A

as needed

177
Q

ad lib

A

as desired

NURS 105 - Medical Terminology (13 decks)

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