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Medical Language

TermDefinition
" SOAP Method " S - Subjective: what patient says. O - Objective: What the test reveal. A - Assessment: Analysis of the Subjective and Objective information. P - Plan: The course of action for the patient.
Subjective Terms Acute vs. Chronic Progressive vs. exacerbation Abrupt Symptom Febrile vs. Afebrile Noncontributory Malaise
Objective Terms Things that are seen: Alert Oriented Things that are heard: Auscultation Percussion Things that are felt: Palpation Descriptions of what is observed: Unremarkable Marked
Assessment Terms Impression Diagnosis Differential diagnosis Benign vs. malignant Degeneration Etiology vs. idiopathic Remission Recurrent
Plan Terms Impression Diagnosis Differential diagnosis Benign vs. malignant Degeneration Etiology vs. idiopathic Remission Recurrent
Anatomical position a person standing face forward, arms at the side with palms forward.
Common on Health Records VS (vital signs) are made up of the HR (heart rate) RR (respiratory rate), BP (blood pressure), and T (temperature) Ht – height Wt – weight BMI – body mass index I/O – input/output
Common on Health Records Dx – diagnosis DDx – differential diagnosis Tx – treatment Rx – prescription Hx (history) PMHx (past medical history); FHx (family history) H&P – history and physical CC – chief complaint
Areas of the Health Care Facility Pre-op: This area prepares the patient for surgery. OR: operation room. PACU: Post anesthesia care unit. Post-op: Post operative room. ICU: intensive care unit
Health professionals Pharmacist Ultrasonographer Pharmacy technician Register Nurse Patient service coordinator Medical transcriptionist Pathologist Medical laboratory technician Phlebotomist Radiologist
Body Planes and Orientation Proximal Coronal Ipsalateral Lateral Sagital Craneal Distal Dorsal
Created by: Nicolle 26
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