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What is a Subjective Data in the medical note?
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SOAP Med Vocabulary
SOAP Word parts, germs and abbreviations Chapter 2
| concept | Definition |
|---|---|
| What is a Subjective Data in the medical note? | It is a Description of the problem in the patient's own words |
| What is a Objective Data in the medical note? | It is a Data collected to assist in understanding the nature of the problem |
| What is an Assessment in the medical note? | It is a Cause of the problem |
| What is a Plan in the medical note? | It is a Treatment with medicine or a procedure |
| Medication prescription | A medical professional's directions for a patient's |
| Emergency department note | Documents a patient's emergency department visit |
| Daily hospital note/progress note | Documents a patient's progress during a daily hospital visit |
| Radiology report | Documents an imaging procedure by a radiologist |
| Pathology report | Documents a pathology procedure |
| Admission summary | Documents a patient's admission to the hospital |
| Operative report | Documents a surgery |
| Clinic note | Documents a patient visit in an office setting |
| Consult note | Document sent to a primary physician, usually by a specialist, to give an opinion on a more challenging problem |
| Discharge summary | Documents a patient's admission and hospital stay (usually a longer stay) |
| Chief complaint | The main reason for a visit |
| Past surgical history | Any past surgeries |
| Social history | Mainly health habits, like smoking, drinking, drug use, or sexual practices |
| History of present illness | The story of the patient's problem |
| Family history | Any significant illnesses that run in the patient's family |
| Past medical history | Other significant past illnesses, like high blood pressure, asthma, or diabetes |
| Review of systems | Any symptoms not directly related to the main problem |
| What data make up the subjective data? | 1. Duration of the problem, 2. The quality of the problem, 3. Any exacerbating or relieving factors for that problem |
| Vocabulary from the subjective part: Acute | It just started recently or is a sharp, severe symptom |
| Vocabulary from the subjective part: Chronic | It has been going on for a while now. |
| Vocabulary from the subjective part: Exacerbation | It is getting worse. |
| Vocabulary from the subjective part: Abrupt | All of a sudden |
| Vocabulary from the subjective part: Febrile | To have a fever |
| Vocabulary from the subjective part: Malaise | Not feeling well |
| Vocabulary from the subjective part: Progressive | More and more each day |
| Vocabulary from the subjective part: Symptom | Something a patient feels |
| Vocabulary from the subjective part: Noncontributory | Not related to this specific problem |
| Vocabulary from the subjective part: Lethargic. | A decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick |
| Vocabulary from the subjective part: Genetic/hereditary. | It runs in the family |
| What data make up objective data? | 1. The patient's physical exam 2. Any laboratory findings 3. Imaging studies performed at the visit. |
| Vocabulary from the objective part: Alert | Able to answer questions; responsive; interactive |
| Vocabulary from the objective part: Oriented | Being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented * 3" |
| Vocabulary from the objective part: Marked. | It really stands out |
| Vocabulary from the objective part: Unremarkable | Another way of saying normal |
| Vocabulary from the objective part: Auscultation | To listen |
| Vocabulary from the objective part: Percussion | To hit something and listen to the resulting sound or feel for the resulting vibration |
| Vocabulary from the objective part: Palpation. | To feel |
| What data make up an assessment? | 1. A diagnosis 2. An identification of a problem, or a list of possibilities for the diagnosis |
| What is a differential diagnosis? | A list of possibilities for the diagnosis |
| Vocabulary from the Assessment: Impression | It is another way of saying assessment |
| Vocabulary from the Assessment: Diagnosis | It is what the health care professional thinks the patient has |
| Vocabulary from the Assessment: Differential diagnosis | It is a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
| Vocabulary from the Assessment: Benign | Safe |
| Vocabulary from the Assessment: Malignant | Dangerous; a problem |
| Vocabulary from the Assessment: Degeneration | to be getting worse |
| Vocabulary from the Assessment: Remission | To get better or improve; most often used when discussing cancer; remission does not mean cure |
| Vocabulary from the Assessment: Idiopathic | No known specific cause; it just happens |
| Vocabulary from the Assessment: Localized | Stays in a certain part of the body |
| Vocabulary from the Assessment: Systemic/generalized | All over the body (or most of it) |
| Vocabulary from the Assessment: Prognosis | The chance for things getting better or worse |
| Vocabulary from the Assessment: Occult | Hidden |
| Vocabulary from the Assessment: Lesion | Diseased tissue |
| Vocabulary from the Assessment: Recurrent | To have again |
| Vocabulary from the Assessment: Sequela | A problem resulting from a disease or injury |
| Vocabulary from the Assessment: Pending | Waiting for |
| Vocabulary from the Public health: Pathogen | The organism that causes the problem |
| Vocabulary from the Public health: Morbidity | The risk for being sick |
| Vocabulary from the Public health: Mortality | The risk for dying |
| Vocabulary from the Public health: Etiology | The cause |
| What is a Plan in a medical note? | It is a course of action consistent with the assessment |
| What data make up a plan? | It consist of collecting further data to help arrive at a more accurate diagnosis |
| Vocabulary from the plan: Disposition | 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, the ICU, normal hospital bed) |
| Vocabulary from the plan: Discharge | Literally, to unload; it has two meanings: * 1. to send home (to unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (your body unloading a fluid) |
| Vocabulary from the plan: Palliative | Treating the symptoms, but not actually getting rid of the cause |
| Vocabulary from the plan: Observation | Watch, keep an eye on |
| Vocabulary from the plan: Reassurance | To tell the patient that the problem is notserious or dangerous |
| Vocabulary from the plan: Supportive care | To treat the symptoms and make the patient feel better |
| Vocabulary from the plan: Sterile | Extremely clean, germ - free conditions; especially important during medical procedures and surgery |
| Vocabulary from the Public health: Prophylaxis | Preventive treatment |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care unit |
| PACU | post-anesthesia care unit |
| BMI | body mass index (measurement of body tat based on neignt and weignt) |
| I/0 | intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output) |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Rx | prescription |
| H&P | history and physical |
| Tx | treatment |
| Hx | history |
| CC | chief complaint (the main reason for the visit) |
| HEENT | head, eyes, ears, nose, and throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodation |
| NAD | no acute distress (the patient does not display any intense symptoms) |
| CV | cardiovascular |
| RRR | regular rate and rhythm (description of a normal heart on exam) |
| CTA | clear to auscultation (description of normal-sounding lungs) |
| WDWN | well developed, well nourished (the patient is growing or has grown appropriately and does not appear to be malnourished) |
| A&O | alert and oriented (the patient can answer questions and is aware of what's going on) |
| WNL | within normal limits |
Created by:
dsolorzano2
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