Introduction to Health Records SOAP Terms
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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| Acute | it just started recently or is a sharp, severe sympton
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| Chronic | it has been going on for a while now
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| Exacerbation | it is getting worse
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| Abrupt | all of a sudden
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| Febrile | to have a fever
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| Afebrile | to not have a fever
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| Malaise | not feeling well
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| Progressive | more and more each day
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| Symptom | something a patient feels
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| Noncontributory | not related to this specific problem
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| Lethargic | a decrease in level of consciousness
(in a medical record, this generally indicates that the patient is really sick)
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| Genetic / Hereditary | it runs in the family
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| Alert | able to answer questions ; responsive; interactive
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| Oriented | being aware of who he/she is, where he/she is, and the current time (a patient who is aware of all three is "oriented x 3")
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| Marked | it really stands out
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| Unremarkable | another way of saying normal
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| Auscultation | to listen
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| Percussion | to hit something and listen to the resulting sound or feel for the resulting vibration
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| Palpation | to feel
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| Impression | another way of saying assessment
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| Diagnosis | what the health care professional thinks the patient has
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| Differential Diagnosis | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
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| Benign | safe
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| Malignant | dangerous; a problem
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| Degeneration | to be getting worse
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| Etiology | the cause
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| Remission | to get better or improve (most often used when discussing cancer; DOES NOT MEAN CURE)
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| Idiopathic | no known specific cause; it just happens
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| Localized | stays in a certain part of the body
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| Systemic / Generalized | all over the body (or most of it)
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| Morbidity | risk for being sick
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| Mortality | risk for dying
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| Prognosis | the chances for things getting better or worse
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| Occult | hidden
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| Pathogen | the organism that causes the problem
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| Lesion | diseased tissue
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| Recurrent | to have again
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| Sequelae | a problem resulting from a disease or injury
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| Pending | waiting for
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| Disposition | what happened to the patient at the end of the visit (often used at the end of ED notes to reverence where the patient went after the visit such as home, ICU, normal hospital bed, etc.)
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| Discharge | to send home OR fluid coming out of a part of the body
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| Prophylasis | preventive treatment
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| Palliative | treating symptoms, but not actually getting rid of the cause
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| Observation | watch, keep an eye on
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| Reassurance | to tell the patient that the problem is not serious or dangerous
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| Supportive Care | to treat the symptoms and make the patient feel better
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| Sterile | extremely clean, germ-free conditions
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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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