SOAP - Common Terms

Question 1

Acute

Answer 1

it just started recently or is a sharp, sever symptom

(Subjective)

Question 2

Chronic

Answer 2

its been going on for awhile

(Subjective)

Question 3

Exacerbation

Answer 3

its getting worse

(Subjective)

Question 4

Abrupt

Answer 4

all of a sudden

(Subjective)

Question 5

Febrile

Answer 5

to have a fever

(Subjective)

Question 6

Afebrile

Answer 6

to not have a fever

(Subjective)

Question 7

Malaise

Answer 7

not feeling well

(Subjective)

Question 8

Progressive

Answer 8

more and more each day

(Subjective)

Question 9

Symptom

Answer 9

something a patient feels

(Subjective)

Question 10

Impression

Answer 10

another way of saying assessment

(Assessment)

Question 11

Diagnosis

Answer 11

what the health care professional thinks the patient has

(Assessment)

Question 12

Differential diagnosis

Answer 12

a list of conditions the patient may have

(Assessment)

Question 13

Benign

Answer 13

safe

(Assessment)

Question 14

Malignany

Answer 14

dangerous; a problem

(Assessment)

Question 15

Degeneration

Answer 15

to be getting worse

(Assessment)

Question 16

Remission

Answer 16

to get better or improve. It does not mean cured.

(Assessment)

Question 17

Idiopathic

Answer 17

no know specific cause; it just happens

(Assessment)

Question 18

Localized

Answer 18

stays in a certain part of the body

(Assessment)

Question 19

Systemic / Generalized

Answer 19

all over the body, or most of it

(Assessment)

Question 20

Prognosis

Answer 20

The chances of getting better or worse

(Assessment)

Question 21

Occult

Answer 21

hidden

(Assessment)

Question 22

Lesion

Answer 22

diseased tissue

(Assessment)

Question 23

Recurrent

Answer 23

to have again

(Assessment)

Question 24

Sequela

Answer 24

a problem resulting from a disease or injury

(Assessment)

Question 25

Pending

Answer 25

waiting for (Assessment)

Question 26

Pathogen

Answer 26

the organism that causes the problem Public Heath Term (Assessment)

Question 27

Morbidity

Answer 27

the risk for being sick Public Heath Term (Assessment)

Question 28

Mortality

Answer 28

the risk for dying Public Heath Term (Assessment)

Question 29

Etiology

Answer 29

the cause Public Heath Term (Assessment)

Question 30

Alert

Answer 30

able to answer questions; responsive, interactive (Objective)

Question 31

Oriented

Answer 31

patient is aware of WHO they are, WHERE they are and the current TIME. A patient who is aware of all three is "oriented x 3" (Objective)

Question 32

Marked

Answer 32

it really stands out (Objective)

Question 33

Unremarkable

Answer 33

another way of saying normal (Objective)

Question 34

Auscultation

Answer 34

to listen (Objective)

Question 35

Percussion

Answer 35

to hit something and listen to the resulting sound or to feel the resulting vibrations. Drums are a percussion instrument. (Objective)

Question 36

Palation

Answer 36

to feel (Objective)

Question 37

Disposition

Answer 37

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, ICU, normal hospital bed) (PLAN)

Question 38

Discharge

Answer 38

literally, to unload; two meanings: 1. to send home (to unload the patient) 2. Fluid coming out of the body (body unloading fluid) (PLAN)

Question 39

Palliative

Answer 39

treating the symptoms, but not actually getting rid of the cause (PLAN)

Question 40

Observation

Answer 40

watch, keep an eye on (PLAN)

Question 41

Reassurance

Answer 41

to tell the patient that the problem is not serious or dangerous (PLAN)

Question 42

Supportive Care

Answer 42

to treat the symptoms and make the patient feel better (PLAN)

Question 43

Sterile

Answer 43

extremely clean, germ free conditions; especially important during medical procedures and surgeries (PLAN)

Question 44

Prophylaxis

Answer 44

preventative treatment Public Health Term (PLAN)