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Chapter 2

Abbreviations and Terms

TermDefinition
SOAP Subjective-what the patient says Objective- what the tests reveal Assessment- the analysis of the subjective and objective information. Administered by the healthcare provider. Plan- The course of action for the patient.
Subjective Problems that the patient states they have; problems are translated into medical terms to allow communication of problems to healthcare providers.
Objective Objective is the data collected by the health care provider (test results, scans, etc..)
Assessment Combination of the subjective and objective information gathered, leading to a diagnosis.
Plan This is what the health care provider recommends to the patient regarding their current health status -Often includes medication, surgery, and/or further tests, among other options.
General Subjective Term -Acute vs chronic Acute- Occurs recently, or sharp severe symptoms Chronic- a problem that occurs for a while
General Subjective Term -Febrile Vs. Afebrile Febrile- has a fever Afebrile- Does not have a fever
General Objective Term -Things that are seen --Alert --oriented Alert- Patient ca answer questions; responsive, interactive Oriented- Patient knows who they are, where they are, and what time it is
General Objective Term -Things that are heard: --Auscultation --Percussion Auscultation- To listen (usually with a telescope) Percussion- to hit or strike and then listen for the sound; the returned sound indicates the condition of the body
General Assessment Term -Impression Impression is another word for assessment
General Assessment Term -Differential Diagnosis Based on the subjective and objective data, the health care professional cannot yet determine the diagnosis; for example, vague chest pain could lead to a differential diagnosis of pneumonia or a heart condition.
Created by: mcoles8
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