Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
medical terms 2
| Term | Definition |
|---|---|
| EHR | Electronic Health Record |
| roadmap | The information contained in a patient's records serves as a __________ to their health history detailing previous illnesses and treatments, continuing medical problems, history of family illness, and any current meds. |
| Subjective, Objective, Assessment, Plan (SOAP) | the four general parts of a medical note |
| Subjective | the patient's personal story of health issue: reason for visit, description of problem, timing, previous problems/surgeries, family health issues, current meds/allergies |
| acute | started recently or sharp and severe symptom |
| chronic | has been going on for a while |
| exacerbation | it is 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 this specific problem |
| lethargic | a decrease in level of consciousness, usually means really sick in medical records |
| genetic/hereditary | runs in the family |
| chief complaint | the main reason for a patient's visit |
| history of present illness | the story of the patient's problem |
| review of symptoms | description of individual body symptoms 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 patient's 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 |
| clinic note | document of a visit in an office setting. always follows the SOAP method |
| consult note | a note from a visit to a specialist or consultant |
| emergency department note | a note given to emergency departments in need of information on a patient |
| admission summary | a summary of a patient's physical details upon being admitted to a hospital |
| discharge summary | a note that details when and why a patient was admitted to the hospital, what happened, how the patient felt, and a follow-up plan. |
| operative report | a report after each surgery explaining the procedure, the events that transpired, and patient's outcome |
| daily hospital note/progress note | a document made every day a patient is in a hospital, usually covers how their condition has changed since the day before. |
| radiology report | a note explaining the reason for ordering a radiologic image, how image was performed, and what was seen on the image, and the reviewing radiologist's assessment |
| pathology report | mirrors the same style as a radiology note, but for pathology |
| prescription | a note that doesn't follow SOAP format, it's the plan. |
| 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 |
| post-op | after surgery |
| pre-op | before surgery |
| alert | able to answer questions, responsive |
| oriented | being aware of who they are, where they are, and the current time |
| marked | it stands out |
| unremarkable | normal |
| auscultation | to listen |
| percussion | to hit something and listen to the resulting sound or feel for resulting vibration |
| palpation | to feel |
| impression | assessment |
| diagnosis | what the health care professional thinks the patient has |
| differential diagnosis | list of conditions 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 |
| remission | to get better or improve, most often used when discussing cancer |
| idiopathic | no known specific cause, just happens |
| localized | stays in a certain part of the body |
| systemic/generalized | all over the body or most of the body |
| prognosis | the chances for things getting better or worse |
| occult | hidden |
| lesion | diseased tissue |
| recurrent | to have again |
| sequela | a problem resulting from a disease or injury |
| pending | waiting for |
| disposition | what happened to the patient at the end of the visit, used at end of ED notes to reference where patient went after visit |
| discharge | to send home, or fluid coming out of part of body |
| palliative | treating the symptoms but not the cure |
| observation | watch, keep an eye on |
| reassurance | tell the patient that the problem is not serious or dangerous |
| supportive care | to treat the symptoms and make the patient feel better |
| sterile | extremely clean, germ free conditions |
| proximal | closer to the center |
| distal | farther from center |
| lateral | out to the side |
| medial | toward the middle |
| ventral | the front |
| dorsal | the back |
| cranial | towards top |
| caudal | towards bottom |
| superior | above |
| inferior | below |
| prone | lying down on belly |
| supine | lying down on back |
| contralateral | opposite side |
| ipsilateral | same side |
| unilateral | one side |
| bilateral | both sides |
| dorsum | the top of hand or foot |
| plantar | sole of foot |
| palmar | palm of hand |
| saggital | divides body from left and right |
| coronal | divides body front and back |
| transverse | divides body top to bottom |
| physician | skilled healthcare provider who attended and graduated medical school |
| pediatrician | physician with special training for children |
| surgeon | physician qualified to treat patients surgically by means of operation or invasive procedure |
| anesthesiologist | physician with special training on pain sedation and pain control |
| epidemiologist | specialist in study of causes and distribution of diseases in populations and the use of this data will enhance public health |
| physician assistant (PA) | midlevel healthcare provider who works under the license of a supervising physician, requires postgraduate training |
| nurse practitioner (NP) | nurse with postgraduate training that serves as midlevel healthcare provider, works under supervising physician |
| emergency medical technician | specially trained in evaluating and treating problems with speech and/or swallowing |
| occupational therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from injury |
| respiratory therapist | trained in treating patients respiratory issues under guidance of a healthcare provider |
| dietician | trained in evaluating the nutritional status of a patient and developing diet plan |
| licensed practical nurse (LPN) | trained and certified to provide basic care to a patient |
| registered nurse (RN) | advanced level nurse who has completed an associate's or bachelor's degree, assists with patient care planning and patient education |
| medical assistant | trained to carry out basic administrative and clinical tasks under guidance of a healthcare provider |
| pathologist | 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 | physician 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 healthcare provider |
| ultrasonographer | 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 voice recorded dictations of healthcare providers into text format |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/output |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint |
| HPI | history of present illness |
| ROS | review of systems |
| 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, and throat |
| PERRLA | pupils are equal, round, reactive to light and accomadations |
| NAD | no acute distress |
| CV | cardiovascular |
| RRR | regular rate and rhythm |
| CTA | clear to auscultation |
| 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 |
| IM | intramuscular |
| SC | subcutaneous |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | instructions |
| BID | twice daily |
| TID | three times daily |
| Q | every x (every x hours) |
| QD | daily |
| QID | four times daily |
| QHS | at night |
| AC | before meals |
| PC | after meals |
| prn | as needed |
| ad lib | as desired |
Created by:
banditbandit
Popular Medical sets