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Med Terminology Ch.2
Word parts, terms, and abbreviations
| Term | Definition |
|---|---|
| Sequelae | A problem resulting from injury or disease |
| NKDA | No Known Drug Allergies |
| PERRLA | Pupils are Equal, Round and Reactive to Light and Accommodation |
| What does the 'S' stand for in a SOAP note? | Subjective (the problem in the patient's own words) |
| What does the 'O' stand for in a SOAP note? | Objective (the investigative process; consists of the patient's physical exam, laboratory findings, and imaging studies that occurred during the patient's visit) |
| What does the 'A' stand for in a SOAP note? | Assessment (a logical analysis; An assessment could be a diagnosis, an identification of a problem, or a list of possibilities for the diagnosis, which is known as a differential diagnosis) |
| What does the 'P' stand for in a SOAP note? | Plan (provider formulates a plan; the plan could be a treatment with medicine or a procedure. It could also consist of collecting further data to help arrive at a more accurate diagnosis) |
| WDWN | Well-Developed and Well-Nourished (patient is growing or has grown appropriately and does not appear to be malnourished) |
| Palliative | treating the symptoms, but not actually getting rid of the cause |
| Prophylaxis | Preventative treatment |
| Caudal | Directional term meaning toward the bottom |
| Ipsilateral | Directional term meaning same sides |
| Contralateral | Directional term meaning opposite sides |
Created by:
Sfritz6
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