Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
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 |
Created by:
jcampbell310