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Health Records

Medical Terminology- Ch 2

What does SOAP stand for? Subject Objective Assessment Plan
What does the (S) subjective part of health records include? This area of the records indicate the patients experiences and their personal description of the problem (duration of the problem, the quality of the problem, and any relieving factors of the problem) .
What is the (O) objective of health records? This is the investigation process that includes ‘Objective’ data. Objective data comprise the patients physical exam, laboratory findings, and image studies that are preformed at the visit.
What is the (A) assessment in health records? After the gathering of all the patient information, the health care providers will form a logical analysis. The assessment could be a diagnosis, or a list of possibilities for the diagnosis.
What is the (P) plan in health records? The provider will formulate a ‘plan’ or course of action that is consistent with the assessment. The plan can include a treatment with medicine or procedure, or it could consist of collecting further data the help form a more accurate diagnosis.
What is differential diagnosis? The list of possibilities for the diagnosis.
What is a diagnosis? The identification of the actual problem.
What is a SOAP note? A pattern used in writing medicinal notes. This is the baseline of thought in medicine.
What all is included in the (S) subjective part of the health records? The main reason for the visit, a problem description, timing of the problem, previous medical problems/surgeries, family health problems, and any current medications and allergies.
What are general subjective terms? Terms that are commonly used when describing the the chief concern; when the problem began, the severity, any associated problems, and weather anything seems to make the problem worse or better.
Acute (ah-KYOOT) It just started recently or is a sharp, severe symptom.
Chronic (KRAWN-ic) It has been going on for a while now.
Exacerbation (eks-AS-er-BAY-shun) It has been going on for a while now.
Abrupt (ah-BURPT) All of the sudden.
Febrile (FEH-brail) To have a fever.
Afebrile (uh-FEB-ril) To not have a fever.
Malaise (mah-LAYZ) Not feeling well.
Progressive (proh-GREH-siv) More and more each day.
Symptom (SIM-tom) Something a patient feels.
Noncontributory (NON-kon-TRIH-byoo-TOR-ee) Not retaliated to a specific problem.
Lethargic (lah-THAR-jik) A decrease in levels of consciousness; in a medical record, this is generally an indication that the patient is really sick.
Genetic/Hereditary (jen-ET-ik) / (heh-RED-ih-TER-ee) It runs in the family.
What are general objective terms? Terms that are used to describe the interaction with the patient.
Alert (ah-LERT) Able to answer questions.
Oriented (OR-ee-EN-ted) Being aware of who he/she is, where he/she is, and the current date/time. (A patient who is aware of all three is oriented x 3)
Marked (MARKT) It really stands out.
Unremarkable (un-ree-MAR-kah-bul) Another way of saying normal.
Auscultation (aw-skul-TAY-shun) To listen.
Percussion (per-KUSH-un) To hit something and listen for the resulting sound or feel for the resulting vibration.
Palpation (pal-PAY-shun) To feel.
What are general assessment terms? Terms that are used to describe the conclusion to the nature of the problem.
Impression (im-PRESH-un) Another way of saying assessment.
Diagnosis (DAI-ag-NOH-sis) What the health care professional thinks the patient has.
Differential diagnosis (DIF-eh-REN-chal DIA-ag-NOH-sis) A list of conditions the patient may have based on the symptoms exhibited and the results of the exam.
Benign (beh-NAIN) Safe
Malignant (mah-LIG-nant) Dangerous; a problem.
Degeneration (dee-JEN-eh-RAY-shun) To be getting worse.
Remission (rih-MISH-un) To get better or improve; most often used when discussing cancer; does not mean cure.
Idiopathic (ID-ee-oh-PATH-ik) No known specific cause; it just happens.
Localized (LOH-kal-aizd) Stays in a certain part of the body.
Systemic/Generalized (sis-TEM-ik) / (JEN-ral-aizd) All over the body (or most of it)
Prognosis (prawg-NOH-sis) The chances of things getting better or worse.
Occult (ah-KULT) Hidden.
Lesion (LEE-zhun) Diseased tissue.
Recurrent (rih-KUR-ent) To have again.
Sequela (seh-KWEL-eh) A problem resulting from a disease or injury.
Pending (PEN-ding) Waiting for.
Pathogen (PATH-oh-jen) The organism that causes the problem.
Morbidity (mor-BID-it-ee) The risk for being sick.
Mortality (mor-TAL-it-ee) The risk for dying.
Etiology (EET-ee-AWL-oh-jee) The cause.
What are generalized plan terms? Terms that are associated with the plan that lays out what the provider recommends do to do about a patients current health.
Disposition ( dis-poh-ZISH-un) What happens to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed).
Discharge (DIS-charj) Literally, to unload; it has two meanings: 1. To send home (to unload the patient from the health care setting to home). 2. Fluid coming out of a part of the body (your body unloading a fluid).
Palliative (PAL-ee-AH-tiv) Treating the symptoms, but not actually getting rid of the cause.
Observation (OB-zer-VAY-shun) Watch, to keep an eye on.
Reassurance (REE-as-SHUR-ants) To tell the patient that the problem is not serious or dangerous.
Supportive care (suh-POR-tiv kehr) To treat the symptoms and make the patient feel better.
Sterile (STER-ul) Extremely clean, germ-free conditions; especially important during medical procedures and surgery.
Prophylaxis (proh-fih-LAK-sis) Preventive treatment.
Created by: cglaze
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