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Word Parts Ch. 2

Word Parts & Terms from Chapter 2

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
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