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Medical Terminology

TermDefinition
SOAP Subjective, Objective, Assessment, Plan
Clinic Note Documents a visit at a clinic, written by a medical professional
Consult note Provides an expert opinion on a more challenging problem, typically written by a physician, usually a specialist
Emergency Department Note Documents an emergency department visit, written by the ED medical staff.
Admission Summary Documents the admission of a patient to the hospital. Written by a hospital medical professional
Discharge Summary Describes when and why the patient was admitted: documents a longer stay, written by a medical professional. Unique because it starts with A (Assessment)
Operative report Documents a surgery in detail, written by a surgeon. Like a discharge summary, starts with A (assessment)
Daily Hospital Note/ Progress Note Documents daily hospital visit, written by a medical professional
Radiology Report Explains reason for the image, how it was performed, what was seen on the image and the radiologists assessment; sometimes includes a recommendation. Written by a radiologist and has no P (Plan)
Pathology Report Provides reasons for test, what was seen on the test and assessment. Written by a pathologist and has no P (plan)
Prescription Provides directions for the medication. Written by a medical professional. Only has the Plan
Created by: emilyflook
 

 



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