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SOAP

Subjective, Objective, Assessment, Plan

TermDefinition
acute (ah-KYOOT) it just started recently or is a sharp, severe symptom
abrupt (ah-BRUPT) all of a sudden
lethargic (lah-THAR-jik) a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick
oriented (OR-ee-EN-ted) 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 x 3"
auscultation (aws-kul-TAY-shun) to listen
percussion (per-KUH-shun) to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument
benign (beh-NAIN) safe
etiology (ee-tee-AW-loh-jee) the cause
occult (ah-KULT) hidden
prophylaxis (PROH-fuh-LAK-sis) preventive treatment
palliative (PA-kee-ah-tiv) treating the symptoms, but not actually getting rid of the cause
sterile (STEH-ril) extremely clean, germ-free conditions; especially important during medical procedures and surgery