Intro to Health Records
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| SOAP method | subjective, objective, assessment, plan
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| subjective | what the patient says
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| objective | what the test reveal, body images, provider observations
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| assessment | the analyisis of the subjective and objective information, performed by the health care provider
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| plan | the course of action for the patient
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| acute | occurs recently, or sharp severe symptoms
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| chronic | a problem that occurs for a while
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| abrupt | occurs suddenly
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| febrile | has a fever
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| afebrile | does not have a fever
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| malaise | not feeling well
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| progressive | worsening of symptoms
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| exacerbation | worsening of a condition
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| symptom | what the patient feels
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| noncontributory | patient's symptom is not related to the current problem
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| lethargic | a decrease in level of consciousness
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| genetic/hereditary | it runs in the family
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| alert | patient can answer questions, responsive, interactive
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| oriented | patient knows who they are, where they are, and what time it is (current date/time)
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| auscultation | to listen (with a stehoscope)
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| percussion | to hit or strike and then listen for the sound, the returned sound indicates the condition of the body
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| palpation | to feel something, how something feels can indicate it's condition, be it normal or abnormal
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| unremarkable | normal
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| marked | it stands out
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| impression | another word for assessment
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| diagnosis | using the subjective and objective data to determine the patient's condition
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| differential diagnosis | based on the subjective and objective data, the health care profession CANNOT yet determine the diagnosis
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| benign | not cancerous
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| malignant | cancerous
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| degeneration | getting worse
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| etilogy | the cause
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| idopathic | no known cause
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| remission | no longer having the symptoms of a disease, usually used when referring to cancer
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| recurrent | to have again
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| mobidity | risk of being sick or diseased
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| mortality | risk for dying
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| prognosis | chance of getting better or worse
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| localized | one area
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| system/generalized | over a large area of body system
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| occult | hidden
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| pathogen | organism that causes the disease
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| lesion | diseased tissue
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| sequelae | result of disease or injury
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| pending | waiting for
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| dispostion | where the patient went at the conclusion for the visit
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| discharge | to send home, fluid coming out of a part of the body
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| prophylaxis | preventative treatment
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| palliative | relieve symptoms, but not cure
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| observation | to watch
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| reassurance | actions that make the patient feel better
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| supportive care | treat symptoms to make the patient feel better
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| sterile | extremely clean, germ-free conditions
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| proximal | pertaining to the trunk of the body-closer to the
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| distal | pertaining to the trunk of the body-further away
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| lateral | away from the center of the body
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| medial | closer to the center of the body
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| ventral, antral, anterior | front of the body
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| dorsal/posterior | back of the body
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| superior | above
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| inferior | below
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| cranial/caudal | head/tail
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| supine | lying on the back
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| prone | lying on the belly
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| ipsilateral | same side
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| contralateral | opposite side
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| unilateral/bilateral | one side/two sides
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| plantar/palmar | sole of the foot, palm of hand
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| dorsum | top/back (hand/foot)
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| coronal plane | divides anterior and posterior
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| sagittal plane | divides body right and left
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| transverse plane | divides body top and bottom
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| chief complaint/ CC | main reason for the patient's visit
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| history of present illness/ HPI | story of the patient's problem
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| review of systems /ROS | description of individual body systems in order to discover andy symptoms not directly related to the main problem
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| past medical history /PMHx | other significant past illnesses
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| past surgical history / PSHx | any of the patient's past surgeries
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| family history | any significant illnesses that run in the patient's family
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| social history | a record of habits like smoking, drinking, drug abuse..
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| I/O | fluid input/output
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| H&P | history and physical
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| PE | physical exam
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| PCP | primary care provider
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| f/u | follow up
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| h/o | history of
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| PERRLA | pupils equal, round and reactive to light and accommodation
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| NOS | not otherwise specified
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| RRR | regular rate and rhythm
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| CTA | clear to auscultation
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| A&O | alert and oriented
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| NAD | no acute distress
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| PO | by mouth (per os)
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| NPO | nothing by mouth (nil per os)
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| IV | intravenous
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| SC | subcutaneous
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| CVL | central venous line
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| IM | intramuscular
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| PR | per rectum (anal)
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| prn | as needed
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| QID | 4x's a day
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| QD | every day
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| AC | before meals
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| TID | 3xs a day
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| BID | 2sx a day
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| PC | after meals
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| QHS | at night
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Created by:
cynmur1110
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