Common Charting Terms

Question 0

Objective

Answer 0

O in SOAPS. Info gathered (lab results, heart rate, blood pressure, etc)

Question 1

Subjective

Answer 1

S in SOAPS. Info the patient describes (symptoms and complaints)

Question 2

Assessment

Answer 2

A in SOAPS. The assessment plan in usually one sentence describing the patients condition

Question 3

Plan

Answer 3

P in SOAPS. The plan for the patient (get a cast, take this medication, etc)

Question 4

Acute

Answer 4

A condition with severe symptoms and a short course

Question 5

Benign

Answer 5

Mild; non cancerous

Question 6

Chronic

Answer 6

A condition that develops slowly and persists over time

Question 7

Degeneration

Answer 7

Gradual, progressive deterioration of body structure or function over time

Question 8

Diagnosis

Answer 8

Physicians determination of the existence of disease based on objective/subjective findings

Question 9

Etiology

Answer 9

Cause of a disease

Question 10

Exacerbation

Answer 10

Increase in severity; to get worse

Question 11

Febrile

Answer 11

Having an elevated temperature

Question 12

Gross

Answer 12

Visible to the naked eye

Question 13

Idiopathic

Answer 13

Lacking a clearly defined cause

Question 14

Localized

Answer 14

Confined to a specific area

Question 15

Malignant

Answer 15

Harmful, cancerous, or invasive

Question 16

Marked

Answer 16

Meaningful, noteworthy, important

Question 17

Morbidity

Answer 17

State or presence of disease

Question 18

Mortality

Answer 18

Death

Question 19

Prognosis

Answer 19

Knowledgeable prediction of the outcome of a disease

Question 20

Progressive

Answer 20

Continuing increase in the severity of signs and symptoms of a disease. Can be good or bad

Question 21

prophylaxis

Answer 21

Measure that prevents

Question 22

Recurrent

Answer 22

Happening repeatedly after a period of inactivity

Question 23

Systemic

Answer 23

Throughout the body

Question 24

Unremarkable

Answer 24

Unimportant, not meaningful

Question 25

Inhalation

Answer 25

Inhaling, breathing in

Question 26

Oral

Answer 26

By word of mouth, spoken rather than written

Question 27

Rectal

Answer 27

Terminal portion if the large intestine

Question 28

Sublingual

Answer 28

Situated or applied under the tongue

Question 29

Topical

Answer 29

Relating or applied directly to a part of the body

Question 30

Transdermal

Answer 30

Application of medicine through the skin

Question 31

Parenteral

Answer 31

Taken somewhere else in the body than the mouth and alimentary canal

Question 32

A

Answer 32

Assessment or analysis

Question 33

ADL

Answer 33

Activities of daily living

Question 34

BP

Answer 34

Blood pressure

Question 35

CC

Answer 35

Chief complaint

Question 36

c/o

Answer 36

Complains of (patients description of symptoms)

Question 37

CP

Answer 37

Chest pain

Question 38

D/C

Answer 38

Discontinue

Question 39

⬇️

Answer 39

Decrease or decreasing

Question 40

Dx

Answer 40

Diagnosis

Question 41

H & P

Answer 41

History and physical

Question 42

Ht

Answer 42

Height

Question 43

Hx

Answer 43

Personal medical HISTORY

Question 44

ICU

Answer 44

Intensive care unit

Question 45

⬆️

Answer 45

Increase or increasing

Question 46

IP

Answer 46

Inpatient

Answer 47

Left

Question 48

NKA

Answer 48

No known allergies

Question 49

NKDA

Answer 49

No known drug allergies

Question 50

O with ➖ through it

Answer 50

None

Question 51

OP

Answer 51

Outpatient

Question 52

OR

Answer 52

Operating room

Question 53

P

Answer 53

Pulse

Question 54

PE

Answer 54

Physical examination

Question 55

PI

Answer 55

Present illness

Question 56

Postop

Answer 56

Recovery room

Question 57

Preop

Answer 57

Pre-operating area

Question 58

pt

Answer 58

Patient

Question 59

Px

Answer 59

Physical examination

Question 60

R

Answer 60

Respirations

Answer 61

Right

Question 62

R/O

Answer 62

Rule out

Question 63

ROM

Answer 63

Range of motion

Question 64

ROS

Answer 64

Review of symptoms

Question 65

SOB

Answer 65

Shortness of breath

Question 66

S

Answer 66

Signs

Question 67

Sx

Answer 67

Symptoms

Question 68

T

Answer 68

Temperature

Question 69

Tx

Answer 69

Treatment

Question 70

VS

Answer 70

Vital signs

Question 71

WNL

Answer 71

Within normal limits

Question 72

Wt.

Answer 72

Weight

Question 73

➖ Over a

Answer 73

Before