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Intro Health Records
Medical Terminology
| Question | Answer |
|---|---|
| Soap | subjective |
| sOap | objective |
| soAp | assessment |
| soaP | plan |
| subjective | what the patient says |
| objective | what the tests reveal |
| assessment | the analysis of the subjective and objective information; performed by the health care provider |
| plan | the course of action for the patient |
| acute | (subjective) just started recently or is sharp and severe |
| chronic | (subjective) has been going on for a while |
| abrupt | (subjective) all of a sudden |
| febrile | (subjective) fever |
| afebrile | (subjective) no fever |
| malaise | (subjective) not feeling well |
| progressive | (subjective) more and more each day |
| exacerbation | (subjective) it's getting worse |
| symptom | (subjective) something a pt feels |
| noncontributory | (subjective) not related to this specific problem |
| lethargic | (subjective) decreased energy level, usually a sign of severe sickness |
| genetic/hereditary | (subjective) runs in the family |
| alert | (objective) able to answer questions, responsive reactive (seen) |
| oriented | (objective) being aware of who they are, where they are, and the current time. a pt aware of all three is "oriented X 3" (seen) |
| auscultation | (objective) to listen (heard) |
| percussion | (objective) to hit something and listen to the resulting sound or feel the resulting vibration (heard) |
| palpation | (objective) to feel (felt) |
| unremarkable | (objective) normal (observed) |
| marked | (objective) really stands out (observed) |
| differential diagnosis | (assessment) a list of possibilities for the diagnosis |
| impression | (assessment) another way of saying assessment |
| diagnosis | (assessment) what the health care professional thinks the pt has |
| benign | (assessment) safe |
| malignant | (assessment) dangerous, a problem |
| degeneration | (assessment) to be getting worse |
| etiology | (assessment) the cause |
| idiopathic | (assessment) no known specific cause, it just happens |
| remission | (assessment) to get better or improve, does not mean cure |
| recurrent | (assessment) to have again |
| morbidity | (assessment) the risk for being sick |
| mortality | (assessment) the risk for dying |
| prognosis | (assessment) the chances for things getting better or worse |
| localized | (assessment) stays in a certain part of the body |
| systemic/generalized | (assessment) all over the body, or most of it |
| occult | (assessment) hidden |
| pathogen | (assessment) the organism that causes the problem |
| lesion | (assessment) diseased tissue |
| sequela | (assessment) a problem resulting from a disease or injury |
| pending | (assessment) waiting for |
| disposition | (plan)what happened to the pt at the end of the visit (home, icu, normal hospital bed) |
| discharge | (plan) to "unload" (send pt home) |
| prophylaxis | (plan) preventative treatment |
| palliative | (plan) treating the symptoms but not actually getting rid of the cause |
| observation | (plan) watch, keep an eye on |
| reassurance | (plan) to tell the pt the problem is not serious or dangerous |
| supportive care | (plan) to treat the symptoms and make the pt feel better |
| sterile | (plan) extremely clean, germ-free conditions |
| dorsum | top of hand or foot |
| 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 (PA) | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
| nurse practitioner (NP) | 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 (LPN) | trained and certified to provide basic care to a pt |
| licensed vocational nurse (LVN) | trained and certified to provide basic care to a pt |
| 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 | trained in performing laboratory testing on bodily fluids |
| 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 |
| chief complaint | the main reason for the pt visit |
| history of present illness | the story of the pt problem |
| review of systems | description of individual body systems in order to discover any symptoms not directly related to the main problem |
| past medical history | other significant past illnesses, like high blood pressure, asthma, or diabetes |
| past surgical history | any of the pt past surgeries |
| family history | any significant illnesses that run in the patient’s family |
| social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care unit |
| PACU | post-anesthesia care unit |
| L&D | labor and delivery |
| OR | operating room |
| pre-op | before surgery |
| post-op | after surgery |
| (R) | right |
| (L) | left |
| (B) | bilateral |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Wt | weight |
| Ht | height |
| BMI | body mass index (measurement of body fat based on height and weight) |
| I/O | intake/output (the amount of fluid a pt has taken in and produced) |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint (main reason for visit) |
| HPI | history of present illness (the story of the symptoms) |
| ROS | review of systems (anything else not directly related to CC) |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| Pt | patient |
| y/o | years old |
| h/o | history of |
| PCP | primary care provider |
| f/u | follow up |
| SOB | shortness of breath |
| HEENT | head, eyes, ears, nose, throat |
| PERLA | pupils are equal, round, and reactive to light and accommodation |
| NAD | no acute distress (pt does not display any intense symptoms) |
| CV | cardiovascular |
| RRR | regular rate and rhythm (description of normal heart on exam) |
| CTA | clear to auscultation (normal sounding lungs) |
| WDWN | well developed, well nourished |
| A&O | alert and oriented |
| WNL | within normal limits |
| NOS | not otherwise specified |
| NEC | not elsewhere classified |
| PO | per os (by mouth) |
| NPO | nil per os (nothing by mouth) |
| PR | per rectum (anal) |
| IM | intramuscular |
| SC | subcutaneous (under skin) |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripheral inserted central catheter |
| Sig | intrustions |
| Bid | twice daily |
| Tid | three times daily |
| Q | every x (Q4hr would be every 4 hours) |
| QD | daily |
| QID | 4 times daily |
| QHS | at night |
| AC | before meals |
| PC | after meals |
| prn | as needed |
| ad lib | as desired |
Created by:
drlake91
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