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Medical Records
Chapter 2 Medical Records & Abbreviations Flash Cards
| Term | Definition |
|---|---|
| Auscultation (aws-kul-TAY-shun) | To listen. (Usually referred to for listening to the sounds of the heart, GI tract and lungs via stethoscope.) |
| Sequelea (seh-KWEL-uh) | A problem resulting from disease or injury. |
| Impression (im-PREH-shun) | Also known as the Assessment; part of the S.O.A.P method. Information and data gathered from labs, imaging and other tests run. Could be a Diagnosis - Dx, An identification of a problem or a list of possibilities aka a DDx - Differential Diagnosis. |
| Sagittal (SA-jih-tal) | Divides the body into R/L slices or portions. Latin for: Arrow "sagitta" (to divide the body in half.) |
| Ipsilateral (IP-shi-LA-ter-al) | On the same side. Example: Patient has Right Ipsilateral fractures on the femur and humerus. (Fractured the arm and leg on the right side.) |
| Caudal (KOW-dal) | Toward the bottom. Latin for "tail." Think of the dog image with an arrow from the head to and through the tail. |
| Palliative (PA-lee-ah-tive) | Treating a patient for symptoms, but not ridding the cause. |
| NEC NOS | Not Elsewhere Classified. Not Otherwise Specified. |
| NAD | No Acute Distress Ex. Patient shows NAD at visit. |
| ROS | Review of Symptoms. Anything else NOT directly related to the CC or Chief Complaint (reason for the visit.) S part of S.O.A.P (Subjective) |
Created by:
MCasler
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