click below
click below
Normal Size Small Size show me how
Health Records
Medical Terminology
Term | Definition |
---|---|
SOAP | Subjective Objective Assessment Plan |
Acute | just started recently/ sharp, severe symptom |
Chronic | Has been going on for a while now |
Exacerbation | Its getting worse |
Abrupt | All of a sudden |
Febrile | To have a fever |
Afebrile | To not have a fever |
Malaise | Not feeling well |
Progressive | More and more each day |
Symptom | Something a patient feels |
Noncontributory | Not related to the specific problem |
Lethargic | A decrease in level of consciousness; in a medical record; this is usually a sign the patient is really sick |
Genetic/ Hereditary | It runs in the family |
Alert | Able to answer questions; Responsive; Interactive |
Oriented | Being aware of who he/ she is, where he/ she is, & the current time; a patient who is aware of all three is “oriented × 3” |
Marked | It really stands out |
Unremarkable | Normal |
Auscultation | To listen |
Percussion | To hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
Palpation | To feel |
Impression | Assessment |
Diagnosis | What the health care professional thinks the patient has |
Differential Diagnosis | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
Benign | Safe |
Malignant | Dangerous; A problem |
Degeneration | To be getting worse |
Etiology | The cause |
Remission | To get better or improve; not cure |
Idiopathic | No known specific cause; It just happens |
Localized | Stays in a certain part of the body |
Systemic/ Generalized | All over the body (or most of it) |
Morbidity | The risk of being sick |
Mortality | The risk of dying |
Prognosis | The chances of things getting better or worse |
Occult | Hidden |
Pathogen | The organism that causes the problem |
Lesion | Diseased tissue |
Recurrent | To have again |
Sequelae | A problem resulting from disease or injury |
Pending | Waiting for |
Disposition | What happened to the patient at the end of a visit/ where they went after the visit |
Discharge | To send home/ fluid coming out of a part of the body |
Prophylaxis | Preventive treatment |
Palliative | Treating the symptoms but not actually getting rid of the cause |
Observation | Watch/ To keep an eye on |
Reassurance | To tell the patient the problem isn't that serious or dangerous |
Supportive care | To treat symptoms and make the patient feel better |
Sterile | Extremely clean; germ free conditions |
Proximal | Close in to the center |
Distal | Farther away from the center |
Lateral | Out to the side |
Medial | Toward the middle |
Ventral/ Antral/ Anterior | The front The word ventral means stomach |
Dorsal/ Posterior | The back |
Cranial | Toward the top |
Caudal | Toward the bottom |
Superior | Above |
Inferior | Below |
Prone | Lying down on belly |
Supine | Lying down on back |
Contralateral | Opposite side |
Ipsilateral | Same side |
Unilateral | Same side |
Bilateral | Both sides |
Dorsum | Top of the hand or foot |
Plantar | The sole of the foot |
Palmar | The palm of the hand |
Sagittal | Divides the body in slices right to left |
Coronal | Divides the body in slices front to back |
Transverse | Divides the body in top to bottom |
Physician | a skilled health care provider who attended and graduated medical school |
Pediatrician | a physician with special training in caring for children |
Surgeon | a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure |
Anesthesiologist | a physician with special training in pain sedation and pain control |
Physician Assistant | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
Nurse Practitioner | a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician |
Emergency Medical Technician (EMT) | specially trained in the emergency care of a patient before and/or during transport to medical facility |
Speech Therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
Occupational Therapist | specially trained in evaluating and treating problems with performing daily activities at home, school, or work |
Physical Therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
Respiratory Therapist | specially trained in treating patient’s respiratory issues under the guidance of a health care provider |
Dietician | specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan |
Licensed Practical Nurse/ Licensed Vocational Nurse (LPN/ LVN) | trained and certified to provide basic care to a patient |
Registered Nurse (RN) | an advanced level nurse who has completed an associate’s or bachelor’s degree; often assists with patient care planning and patient education |
Medical Assistant | trained to carry out basic administrative and clinical tasks under the guidance of a health care provider |
Pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
Medical laboratory technician | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
Phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
radiologist | a physician specially trained in evaluating images of the body to diagnose illness or injury |
radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
ultrasonagrapher | trained in performing ultrasound imaging on a patient |
pharmacist | trained and licensed in preparing and dispensing medicine |
pharmacy technician | trained to assist a pharmacist with pharmacy-related tasks |
patient service coordinator | handles administrative tasks and coordinates patient care |
medical transcriptionist | trained in converting the voice-recorded dictations of health care providers into text format |