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Health Records
Medical Terminology
| Term | Definition |
|---|---|
| SOAP | Subjective Objective Assessment Plan |
| Acute | just started recently/ sharp, severe symptom |
| Chronic | Has been going on for a while now |
| Exacerbation | Its getting worse |
| Abrupt | All of a sudden |
| Febrile | To have a fever |
| Afebrile | To not have a fever |
| Malaise | Not feeling well |
| Progressive | More and more each day |
| Symptom | Something a patient feels |
| Noncontributory | Not related to the specific problem |
| Lethargic | A decrease in level of consciousness; in a medical record; this is usually a sign the patient is really sick |
| Genetic/ Hereditary | It runs in the family |
| Alert | Able to answer questions; Responsive; Interactive |
| Oriented | Being aware of who he/ she is, where he/ she is, & the current time; a patient who is aware of all three is “oriented × 3” |
| Marked | It really stands out |
| Unremarkable | Normal |
| Auscultation | To listen |
| Percussion | To hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
| Palpation | To feel |
| Impression | Assessment |
| Diagnosis | What the health care professional thinks the patient has |
| Differential Diagnosis | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
| Benign | Safe |
| Malignant | Dangerous; A problem |
| Degeneration | To be getting worse |
| Etiology | The cause |
| Remission | To get better or improve; not cure |
| Idiopathic | No known specific cause; It just happens |
| Localized | Stays in a certain part of the body |
| Systemic/ Generalized | All over the body (or most of it) |
| Morbidity | The risk of being sick |
| Mortality | The risk of dying |
| Prognosis | The chances of things getting better or worse |
| Occult | Hidden |
| Pathogen | The organism that causes the problem |
| Lesion | Diseased tissue |
| Recurrent | To have again |
| Sequelae | A problem resulting from disease or injury |
| Pending | Waiting for |
| Disposition | What happened to the patient at the end of a visit/ where they went after the visit |
| Discharge | To send home/ fluid coming out of a part of the body |
| Prophylaxis | Preventive treatment |
| Palliative | Treating the symptoms but not actually getting rid of the cause |
| Observation | Watch/ To keep an eye on |
| Reassurance | To tell the patient the problem isn't that serious or dangerous |
| Supportive care | To treat symptoms and make the patient feel better |
| Sterile | Extremely clean; germ free conditions |
| Proximal | Close in to the center |
| Distal | Farther away from the center |
| Lateral | Out to the side |
| Medial | Toward the middle |
| Ventral/ Antral/ Anterior | The front The word ventral means stomach |
| Dorsal/ Posterior | The back |
| Cranial | Toward the top |
| Caudal | Toward the bottom |
| Superior | Above |
| Inferior | Below |
| Prone | Lying down on belly |
| Supine | Lying down on back |
| Contralateral | Opposite side |
| Ipsilateral | Same side |
| Unilateral | Same side |
| Bilateral | Both sides |
| Dorsum | Top of the hand or foot |
| Plantar | The sole of the foot |
| Palmar | The palm of the hand |
| Sagittal | Divides the body in slices right to left |
| Coronal | Divides the body in slices front to back |
| Transverse | Divides the body in top to bottom |
| Physician | a skilled health care provider who attended and graduated medical school |
| Pediatrician | a physician with special training in caring for children |
| Surgeon | a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure |
| Anesthesiologist | a physician with special training in pain sedation and pain control |
| Physician Assistant | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
| Nurse Practitioner | a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician |
| Emergency Medical Technician (EMT) | specially trained in the emergency care of a patient before and/or during transport to medical facility |
| Speech Therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
| Occupational Therapist | specially trained in evaluating and treating problems with performing daily activities at home, school, or work |
| Physical Therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
| Respiratory Therapist | specially trained in treating patient’s respiratory issues under the guidance of a health care provider |
| Dietician | specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan |
| Licensed Practical Nurse/ Licensed Vocational Nurse (LPN/ LVN) | trained and certified to provide basic care to a patient |
| Registered Nurse (RN) | an advanced level nurse who has completed an associate’s or bachelor’s degree; often assists with patient care planning and patient education |
| Medical Assistant | trained to carry out basic administrative and clinical tasks under the guidance of a health care provider |
| Pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| Medical laboratory technician | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| Phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| radiologist | a physician specially trained in evaluating images of the body to diagnose illness or injury |
| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonagrapher | trained in performing ultrasound imaging on a patient |
| pharmacist | trained and licensed in preparing and dispensing medicine |
| pharmacy technician | trained to assist a pharmacist with pharmacy-related tasks |
| patient service coordinator | handles administrative tasks and coordinates patient care |
| medical transcriptionist | trained in converting the voice-recorded dictations of health care providers into text format |
Created by:
jeslew7905
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