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Word Parts Ch. 2
Word Parts & Terms from Chapter 2
Term | Definition |
---|---|
SOAP | S: subjective (what patient tells you) O: objective (data collected while interacting with patient, lab results) A: assessment (diagnosis or differential diagnosis) P: plan (what the provider plans to do--medicine, surgery, etc.) |
Subjective terms include: | acute, chronic, progressive, lethargic, genetic/hereditary |
Objective terms include: | alert, orientated, marked, unremarkable, auscultation |
Assessment terms include: | impression, diagnosis, differential diagnosis, benign, malignant, localized, recurrent, remission, pending |
Plan terms include: | discharge, palliative, observation, disposition, prophylaxis, supportive care |
Name the three planes of the body. | Sagittal plane: right/left Coronal (Frontal) plane: front/back Transverse plane: top/bottom, superior/inferior |
Name the sections of a health record. | 1. Chief complaint 2. History of present illness 3. Review of systems 4. Past medical history 5. Past surgical history 6. Family history 7. Social history |
Name the different types of notes (10). | 1. Clinic note 2. Consult note 3. Emergency Department note 4. Admission summary 5. Discharge summary 6. Operative report 7. Daily hospital note / Progress note 8. Radiology report 9. Pathology report 10. Prescription |
Which is the only note that doesn't follow the SOAP method? | Prescription |
Abbreviation for primary care provider | PCP |
Abbreviations used as 'catch-alls' for diagnoses that don't quite fit any specific cause | NOS: not otherwise specified NEC: not elsewhere classified |
The timing abbreviation that means 'as needed' | PRN |
Timing abbreviation that means 'every x' | Q: Q4hrs means every four hours, Q5 days means every 5 days |
This abbreviation means 'nothing by mouth' | NPO |
This abbreviation means 'shortness of breath' | SOB |