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What does each letter in SOAP stand for?
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What is the subjective part of a medical note?
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MED 104
Chapter 2
| Question | Answer |
|---|---|
| What does each letter in SOAP stand for? | S- subjective O- objective A- Assessment P- Plan |
| What is the subjective part of a medical note? | how the patient experiences and personally describes the problem as well as personal and family medical histories. |
| What is the objective part of a medical note? | the investigative process of collecting objective data such as patient's physical exam, any laboratory findings and imaging studies performed at the visit. |
| What is the assessment part of a medical note? | upon gathering all the pertinent information, the health care provider formulates a logical analysis. An assessment could be a diagnosis, and identification of a problem, or a list of possibilities for the diagnosis (differential diagnosis) |
| What is the plan part of a medical note? | a course of action consistent with the assessment such as treatment with medicine or a procedure. It could also consist of collecting further data to help a more accurate diagnosis. |
| what is the definition of acute? | it just started recently or is a sharp, severe syptom |
| what is the definition of chronic? | it has been going on for a while now |
| what is the definition of exacerbation? | it is getting worse |
| what is the definition of abrupt? | all of a sudden |
| what is the definition of febrile? | to have a fever |
| what is the definition of afebrile? | to not have a fever |
| what is the definition of malaise? | not feeling well |
| what is the definition of progressive? | more and more each day |
| what is the definition of symptom? | something a patient feels |
| what is the definition of noncontributory? | not related to this specific problem |
| what is the definition of lethargic? | a decrease level of consciousness; in a medical record, this is generally an indication that the patient is really sick |
| what is the definition of genetic/hereditary? | it runs in the family |
| what is the definition of alert? | able to answer questions; responsive; interactive |
| what is the definition of 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 x 3 |
| what is the definition of marked? | it really stands out |
| what is the definition of unremarkable? | another way of saying normal |
| what is the definition of auscultation? | to listen |
| what is the definition of percussion? | to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
| what is the definition of palpation? | to feel |
| what is the definition of impression? | another way of saying assessment |
| what is the definition of diagnosis? | what the health care professional thinks the patient has |
| what is the definition of differential diagnosis? | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
| what is the definition of benign? | safe |
| what is the definition of malignant? | dangerous; a problem |
| what is the definition of degeneration? | to be getting worse |
| what is the definition of remission? | to get better or improve; most often used when discussing cancer; remission does not mean cure |
| what is the definition of idiopathic? | no known specific cause; it just happens |
| what is the definition of localized? | stays in a certain part of the body |
| what is the definition of systemic/generalized? | all over the body (or most of it) |
| what is the definition of prognosis? | the chances for things getting better or worse |
| what is the definition of occult? | hidden |
| what is the definition of lesion? | diseased tissue |
| what is the definition of recurrent? | to have again |
| what is the definition of sequeia? | a problem resulting from a disease or injury |
| what is the definition of pending? | waiting for |
| what is the definition of pathogen? | the organism that causes the problem |
| what is the definition of morbidity? | the risk for being sick |
| what is the definition of mortality? | the risk for dying |
| what is the definition of etiology? | the cause |
| what is the definition of disposition? | what happened to the patient at the end of the visit |
| what is the definition of discahrge? | to unload 1. to send home 2. fluid coming out of a part of the body |
| what is the definition of pallative? | treating the symptoms, but not actually getting rid of the cause |
| what is the definition of observation? | watch, keep an eye on |
| what is the definition of reassurance? | to tell the patient that the problem is not serious or dangerous |
| what is the definition of supportive care? | to treat the symptoms and make the patient feel better |
| what is the definition of sterile? | extremely clean, germ-free conditions; especially important during medical procedures and surgery |
| what is the definition of prophylaxis? | preventative treatment |
| What does PO stand for? | per os (by mouth) |
| What does NPO stand for? | nil per os (nothing by mouth) |
| What does PR stand for? | per rectum (anal) |
| What does IM stand for? | intramuscular |
| What does SC stand for? | subcutaneous (under the skin) |
| What does IV stand for? | intravenous |
| What does CVL stand for? | central venous line |
| What does PICC stand for? | peripherally inserted central catheter |
| What does Sig stand for? | instructions short for signa, from Latin, for "label" |
| What does BID stand for? | twice daily |
| What does TID stand for? | three times daily |
| What does Q stand for? | every x (EX: Q4hr would mean every 4 hours or Q3 would be every 3 days) |
| What does QD* stand for? | daily |
| What does QID* stand for? | four times daily |
| What does QHS stand for? | at night |
| What does AC stand for? | before meals |
| What does PC stand for? | after meals |
| What does prn stand for? | as needed |
| What does ad lib stand for? | as desired |
Created by:
kasscurtis
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