SOAP Word parts, germs and abbreviations Chapter 2
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| What is a Subjective Data in the medical note? | show 🗑
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| show | It is a Data collected to assist in understanding the nature of the problem
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| What is an Assessment in the medical note? | show 🗑
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| show | It is a Treatment with medicine or a procedure
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| Medication prescription | show 🗑
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| Emergency department note | show 🗑
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| show | Documents a patient's progress during a daily hospital visit
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| Radiology report | show 🗑
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| Pathology report | show 🗑
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| show | Documents a patient's admission to the hospital
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| show | Documents a surgery
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| Clinic note | show 🗑
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| show | Document sent to a primary physician, usually by a specialist, to give an opinion on a more challenging problem
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| Discharge summary | show 🗑
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| Chief complaint | show 🗑
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| show | Any past surgeries
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| show | Mainly health habits, like smoking, drinking, drug use, or sexual practices
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| show | The story of the patient's problem
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| show | Any significant illnesses that run in the patient's family
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| Past medical history | show 🗑
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| Review of systems | show 🗑
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| What data make up the subjective data? | show 🗑
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| show | It just started recently or is a sharp, severe symptom
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| Vocabulary from the subjective part: Chronic | show 🗑
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| show | It is getting worse.
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| show | All of a sudden
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| Vocabulary from the subjective part: Febrile | show 🗑
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| show | Not feeling well
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| show | More and more each day
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| show | Something a patient feels
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| Vocabulary from the subjective part: Noncontributory | show 🗑
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| Vocabulary from the subjective part: Lethargic. | show 🗑
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| show | It runs in the family
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| What data make up objective data? | show 🗑
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| show | Able to answer questions; responsive; interactive
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| Vocabulary from the objective part: Oriented | show 🗑
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| show | It really stands out
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| Vocabulary from the objective part: Unremarkable | show 🗑
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| Vocabulary from the objective part: Auscultation | show 🗑
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| Vocabulary from the objective part: Percussion | show 🗑
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| show | To feel
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| show | 1. A diagnosis
2. An identification of a problem, or a list of possibilities for the diagnosis
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| What is a differential diagnosis? | show 🗑
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| Vocabulary from the Assessment: Impression | show 🗑
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| Vocabulary from the Assessment: Diagnosis | show 🗑
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| Vocabulary from the Assessment: Differential diagnosis | show 🗑
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| Vocabulary from the Assessment: Benign | show 🗑
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| Vocabulary from the Assessment: Malignant | show 🗑
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| show | to be getting worse
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| Vocabulary from the Assessment: Remission | show 🗑
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| Vocabulary from the Assessment: Idiopathic | show 🗑
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| Vocabulary from the Assessment: Localized | show 🗑
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| Vocabulary from the Assessment: Systemic/generalized | show 🗑
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| show | The chance for things getting better or worse
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| Vocabulary from the Assessment: Occult | show 🗑
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| Vocabulary from the Assessment: Lesion | show 🗑
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| show | To have again
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| show | A problem resulting from a disease or injury
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| show | Waiting for
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| show | The organism that causes the problem
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| show | The risk for being sick
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| show | The risk for dying
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| Vocabulary from the Public health: Etiology | show 🗑
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| What is a Plan in a medical note? | show 🗑
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| What data make up a plan? | show 🗑
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| show | 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)
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| show | 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)
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| Vocabulary from the plan: Palliative | show 🗑
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| Vocabulary from the plan: Observation | show 🗑
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| Vocabulary from the plan: Reassurance | show 🗑
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| show | To treat the symptoms and make the patient feel better
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| show | Extremely clean, germ - free conditions; especially important during medical procedures and surgery
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| Vocabulary from the Public health: Prophylaxis | show 🗑
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| CCU | show 🗑
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| show | emergency care unit
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| show | emergency room
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| show | emergency department
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| show | intensive care unit
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| show | pediatric intensive care unit
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| NICU | show 🗑
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| show | surgical intensive care unit
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| show | post-anesthesia care unit
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| show | body mass index (measurement of body tat based on neignt and weignt)
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| show | intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)
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| Dx | show 🗑
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| DDx | show 🗑
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| Rx | show 🗑
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| show | history and physical
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| Tx | show 🗑
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| Hx | show 🗑
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| CC | show 🗑
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| show | head, eyes, ears, nose, and throat
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| PERRLA | show 🗑
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| NAD | show 🗑
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| show | cardiovascular
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| RRR | show 🗑
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| show | clear to auscultation (description of normal-sounding lungs)
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| WDWN | show 🗑
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| show | alert and oriented (the patient can answer questions and is aware of what's going on)
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| show | within normal limits
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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.
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Created by:
dsolorzano2
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