Ch. 2: Intro to Health Records Flashcards
1
Q
What does SOAP stand for?
A
subjective
objective
assessment
plan
2
Q
How a patient experiences and personally describes his or her problem, as well as personal and family medical histories.
A
subjective
3
Q
Data comprised of the physical exam, lab findings, and imaging studies.
A
objective
4
Q
A logical analysis (identify a problem, or a list of possibilities for the diagnosis).
A
assessment
5
Q
A course of action consistent with an assessment.
A
plan
6
Q
acute
A
ah-KYOOT
the problem just started recently, or is a sharp, severe symptom
7
Q
chronic
A
KRaH-nik
the problem has been going on for a while now
8
Q
exacerbation
A
ex-SAS-er-BAY-shun
the problem is getting worse
9
Q
abrupt
A
ah-BRUPT
all of a sudden
10
Q
febrile
A
FEH-brail
to have a fever
11
Q
afebrile
A
AY-FEH-brail
to not have a fever
12
Q
malaise
A
mah-LAYZ
not feeling well
13
Q
progressive
A
proh-GREH-siv
more and more each day
14
Q
symptom
A
SIM-tom
something a patient feels
15
Q
noncontributory
A
NON-kon-TRIB-yoo-TOH-ree
not related to this specific problem
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
17
Q
genetic
hereditary
A
jih-NEH-tik
hah-REH-dih-TEH-ree
a problem runs in the family
18
Q
alert
A
ah-LERT
able to answer questions; responsive; interactive
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”
20
Q
marked
A
MARKT
something really stands out
21
Q
unremarkable
A
un-ree-MARK-ah-bul
another way of saying normal
22
Q
auscultation
A
aws-kul-TAY-shun
to listen
23
Q
percussion
A
per-KUH-shun
to hit something and listen to the resulting sound or feel for the resulting vibration
24
Q
palpation
A
pal-PAY-shun
to feel
25
impression
im-PREH-shun
| another way of saying assessment
26
diagnosis
DAI-ag-NOH-sis
| what the heath care professional thinks the patient has
27
differential diagnosis
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
28
benign
beh-NAIN
| safe
29
malignant
mah-LIG-nant
| dangerous; a problem
30
degeneration
dee-jen-er-AY-shun
| to be getting worse
31
etiology
eh-tee-AW-loh-jee
| the cause
32
remission
reh-MIH-shun
| to get better or improve; most often used when discussion cancer, remission does not mean cure
33
idiopathic
ih-dee-oh-PA-thik
| no known specific cause, it just happens
34
localized
LOH-kah-LAIZD
| stays in a certain part of the body
35
systemic
| generalized
sih-STEM-ik
jen-er-ah-LAIZD
all over the body (or most of it)
36
morbidity
mor-BID-ih-tee
| the risk for being sick
37
mortality
mor-TA-lih-tee
| the risk for dying
38
prognosis
prawg-NOH-sis
| the chances for things getting better or worse
39
occult
ah-KULT
| hidden
40
pathogen
PATH-oh-jin
| the organism that causes the problem
41
lesion
LEE-shun
| diseased tissue
42
recurrent
ree-KUR-ent
| to have again
43
sequelae
seh-KWEL-ah
| a problem resulting from a disease or injury
44
pending
PEN-ding
| waiting for
45
disposition
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)
46
discharge
DIS-charj
literally, to unload
1. to send home
2. fluid coming out of a part of the body
47
prophylaxis
PROH-fuh-LAK-sis
| preventative treatment
48
palliative
PA-lee-ah-tiv
| treating the symptoms, but not actually getting rid of the cause
49
observation
OB-zer-VAY-shun
| to watch or keep an eye on
50
reassurance
ree-ah-SHUR-ants
| to tell the patient that the problem is not serious or dangerous
51
supportive care
suh-POR-tiv kehr
| to treat the symptoms and make the patient feel better
52
sterile
STEH-ril
| extremely clean, germ-free conditions; especially important during medical procedures and surgery
53
proximal
PRAWK-sih-mal
closer in to the center
proximal and approximate come from the same word and mean close
54
distal
DIH-stal
farther away from the center
distal and distant come from the same word and mean far
55
lateral
LA-ter-al
out to the side
think of a quarterback lateraling a football to a running back
56
medial
MEE-dee-al
toward the middle
like the median of a highway
57
ventral
antral
anterior
```
VEN-tral
AN-tral
an-TIH-ree-or
the front
the word ventral means "stomach"
```
58
dorsal
| posterior
DOR-sal
pohs-TEER-ee-or
the back
a dorsal fin on a shark is on its back
59
cranial
KRAY-nee-al
| toward the top
60
caudal
KOW-dal
toward the bottom
from Latin for tail
61
superior
soo-PIH-ree-or
| above
62
inferior
in-FIH-ree-or
| below
63
prone
PROHN
| lying down on belly
64
supine
SOO-pain
| lying down on back
65
contralateral
KON-tra-LA-ter-al
| opposite side
66
ipsilateral
IP-sih-LA-ter-al
| same side
67
unilater
YOO-nih-LA-ter-al
| one side
68
bilateral
BAI-LA-ter-al
| both sides
69
dorsum
DOR-sum
| the top of the hand or foot
70
plantar
PLAN-tar
| the sole of the foot
71
palmar
PAL-mar
| the palm of the hand
72
sagittal
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
coronal (frontal)
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
transverse
tranz-VERS
| divides the body from top to bottom
75
physician
fuh-ZIH-shun
| a skilled health care provider who attended and graduated medical school (MD medical doctor and DO doctor of osteopathy)
76
pediatrician
PEE-dee-ah-TRIH-shun
| a physician with special training in caring for children
77
surgeon
SIR-jen
| a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure
78
anesthesiologist
AN-ehs-THEE-zee-AWloh-jist
| a physician with special training in pain sedation and pain control
79
physician assistant (PA)
fuh-ZIH-shun as-SIS-tant
| a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training
80
nurse practitioner (NP)
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
emergency medical technician (EMT)
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
speech therapist
SPEECH THEH-rah-pist
| specially trained in evaluating and treating problems with speech and/or swallowing
83
occupational therapist
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
physical therapist
FIH-sih-kal THEH-rah-pist
| specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury
85
respiratory therapist
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
dietician
dai-ah-TIH-shun
| specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan
87
licensed practical nurse (LPN)
| licensed vocational nurse (LVN)
LAI-senzd PRaK-tih-kal NIRS
LAI-senzd voh-KAY-shun-al NIRS
trained and certified to provide basic care to a patient
88
registered nurse (RN)
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
medical assistant
MEH-di-kal ah-SIS-tant
| trained to carry out basic administrative and clinical tasks under the guidance of a health care provider
90
pathologist
pah-THAW-loh-jist
| a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
91
medical laboratory technician
med-DIH-kal LAH-broh-tor-ee tek-NIH-shun
| trained in performing laboratory testing on bodily fluids
92
phlebotomist
fleh-BOH-tow-mist
| trained in the removal of blood from the body for diagnostic or therapeutic purposes
93
radiologist
ray-dee-AW-loh-jist
| a physician specially trained in evaluating images of the body to diagnose illness or injury
94
radiology technician
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
ultrasonographer
ul-trah-saw-NAW-grah-fir
| trained in performing ultrasound imaging on a patient
96
pharmacist
FAR-mah-sist
| trained and licensed in preparing and dispensing medicine
97
pharmacy technician
FAR-mah-see tek-NIH-shun
| trained to assist pharmacist with pharmacy-related tasks
98
patient service coordinator
PAY-shent SIR-vis coh-OR-dih-nay-tor
| handles administrative tasks and coordinates patient care
99
medical transcriptionist
MEH-dih-kal tran-SKRIP-shun-ist
| trained in converting the voice-recorded dictations of health care providers into text format
100
chief complaint
the main reason for the patient's visit
101
history of present illness
the story of the patient's problem
102
review of systems
description of individual body systems in order to discover any symptoms not directly related to the main problem
103
past medical history
other significant past illnesses, like HBP, asthma, or diabetes
104
past surgical history
any of the patient's past surgeries
105
family history
any significant illnesses that run in the patient's family
106
social history
a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
107
CCU
coronary care unit
108
ECU
emergency care unit
109
ER
emergency room
110
ED
emergency department
111
ICU
intensive care unit
112
PICU
pediatric intensive care unit
113
NICU
neonatal intensive care unit
114
SICU
surgical intensive care unit
115
PACU
post-anesthesia intensive care unit
116
L&D
labor and delivery
117
OR
operating room
118
post-op
after surgery
119
pre-op
before surgery
120
VS
vital signs
121
T
temperature
122
BP
blood pressure
123
HR
heart rate
124
RR
respiratory rate
125
Ht
height
126
Wt
weight
127
BMI
body mass index
128
I/O
intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)
129
Dx
diagnosis
130
DDx
differential diagnosis
131
Tx
treatment
132
Rx
prescription
133
H&P
history and physical
134
Hx
history
135
CC
chief complaint
136
HPI
history of present illness
137
ROS
review of systems
138
PMHx
present medical history
139
FHx
family history
140
NKDA
no known drug allergies
141
PE
physical exam
142
Pt
patient
143
y/o
years old
144
h/o
history of
145
PCP
primary care provider
146
f/u
follow up
147
SOB
shortness of breath or SOA shortness of air
148
HEENT
head, eyes, ears, nose, and throat
149
PERRLA
pupils equal, round, reactive to light and accommodation
150
NAD
no acute distress
151
CV
cardiovascualr
152
RRR
regular rate and rhythm
153
CTA
clear to auscultation
154
WDWN
well developed, well nourished
155
A&O
alert and oriented
156
WNL
within normal limits
157
NOS
not otherwise specified
158
NEC
not elsewhere classified
159
PO
per os (by mouth)
160
NPO
nil per os (nothing by mouth)
161
PR
per rectum
162
IM
intramuscular
163
SC
subcutaneous
164
IV
intravenous
165
CVL
central venous line
166
PICC
peripherally inserted central catheter
167
Sig
instructions
168
BID
twice daily
169
TID
three times daily
170
Q
every x
171
QD
daily
172
QID
four times daily
173
QHS
at night
174
AC
before meals
175
PC
after meals
176
prn
as needed
177
ad lib
as desired
