SOAP Word parts, germs and abbreviations Chapter 2
Help!
|
|
||||
|---|---|---|---|---|---|
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
dsolorzano2
Popular Medical sets