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Chapter 2

Introduction to Health Records

SOAP An acronym that stands for the four general parts of a medical plan. Note: S-Subject, O - Objective, A - Assessment, and P - Plan
hereditary It runs in the family
percussion To hit something and listen to the resulting sound or feel for the resulting vibration
palliative Treating symptoms but not actually getting rid of the cause
distal Further away from the center of the body
PACU Abbreviation for post-anesthesia care unit.
(B) Symbol for bilateral; both sides.
I/O Abbreviation for intake/output; pertaining to the amount of fluids a patient has taken in and produced. Commonly found on health records
PERRLA Abbreviation of symptoms meaning pupils are equal, round and reactive to light and accommodation.
NAD Abbreviation meaning no acute distress; the patient does not display any intense symptoms