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Ch. 2 Flash Card

Introduction to Medical Records

TermDefinition
Acute Just started recently
Chronic Has been going on awhile
Exacerbation Getting worse
Abrupt All of a sudden
Febrile To have a fever
Malaise Not feeling well
Proximal Closer to the center
Distal Farther away from the center
Anterior The front
Posterior The back
Pediatrician Treats children
Anesthesiologist Specializes in pain control and sedation
EMT Trained an emergency care and transporting patients
Surgeon Treats patients surgically
S.o.a.p Subjective
s.O.a.p Objective
s.o.A.p Assessment
s.o.a.P Plan
CCU Coronary care unit
ECU Emergency care unit
ER Emergency room
ED Emergency department
ICU Intensive care unit
PICU Pediatric intensive care
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
Clinical note When a healthcare professional has seen a patient in an office setting.
Consult Note A note from a specialist or consulting medical professional.
Emergency department note When a patient is seen in an emergency room or urgent care setting.
Admission summary Upon admittance to a hospital, patients must provide medical history and receive a physical exam.
Discharge summary Explains why a patient was admitted, what happened during patient stay, along with any follow up instructions for patient.
Operative report The report the surgeon fills out after surgery, explaining surgery, performed events that transpired during surgery and patients outcome.
Daily hospital note/ Progress note Every day that I patient is admitted, a medical professional must see patient in document visit.
Radiology report Explains reasoning for ordering radiologic image, how it was performed in any findings.
Pathology report Reason for the study, what was seen in detail, and the assessment.
Prescription This is considered the plan. This will detail what medicine is prescribed, Patients instructions, Instructions for pharmacist and Physicians signature.
Created by: Cpickett10
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