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HLHS 101 Ch2

Introduction to Health Records SOAP Terms

Acute it just started recently or is a sharp, severe sympton
Chronic it has been going on for a while now
Exacerbation it is getting worse
Abrupt all of a sudden
Febrile to have a fever
Afebrile to not have a fever
Malaise not feeling well
Progressive more and more each day
Symptom something a patient feels
Noncontributory not related to this specific problem
Lethargic a decrease in level of consciousness (in a medical record, this generally indicates that the patient is really sick)
Genetic / Hereditary it runs in the family
Alert able to answer questions ; responsive; interactive
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")
Marked it really stands out
Unremarkable another way of saying normal
Auscultation to listen
Percussion to hit something and listen to the resulting sound or feel for the resulting vibration
Palpation to feel
Impression another way of saying assessment
Diagnosis what the health care professional thinks the patient has
Differential Diagnosis a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
Benign safe
Malignant dangerous; a problem
Degeneration to be getting worse
Etiology the cause
Remission to get better or improve (most often used when discussing cancer; DOES NOT MEAN CURE)
Idiopathic no known specific cause; it just happens
Localized stays in a certain part of the body
Systemic / Generalized all over the body (or most of it)
Morbidity risk for being sick
Mortality risk for dying
Prognosis the chances for things getting better or worse
Occult hidden
Pathogen the organism that causes the problem
Lesion diseased tissue
Recurrent to have again
Sequelae a problem resulting from a disease or injury
Pending waiting for
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.)
Discharge to send home OR fluid coming out of a part of the body
Prophylasis preventive treatment
Palliative treating symptoms, but not actually getting rid of the cause
Observation watch, keep an eye on
Reassurance to tell the patient that the problem is not serious or dangerous
Supportive Care to treat the symptoms and make the patient feel better
Sterile extremely clean, germ-free conditions
Created by: choover29