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Medical Terms Ch 2

Health Records

TermDefinition
Subjective (S) what the patient says
Objective (O) what the test reveals
Assessment (A analysis performed by healthcare provider
Plan (P) course of action for patient
Acute severe, over a short period of time
Chronic continues over a long period of time
Abrupt sudden, unexpected
Febrile related to fever
Afebrile free from fever
Malaise general feeling of discomfort or illness
Progressive worsens over time
Exacerbation worsening, increase of severity
Symptom something the patient feels
Noncontributory no relation to diagnosis
Lethargic lack of energy or consciousness
Genetic/Hereditary runs in the family
Alert patient is aware and can respond
Oriented patient is aware of self, place, time, situation
Auscultation listening to the sounds of body during examination
Percussion tapping body parts with fingers, hands, or small equipment during examination
Palpation feeling with fingers or hands during examination
Unremarkable nothing abnormal or significant was observed
Marked a significant, noticeable presence
Impression describes symptom or condition
Diagnosis the process of identifying a disease, condition, or injury
Differential diagnosis when symptoms match more than one condition
Benign non cancerous cells
Malignant refers to the presence of cancerous cells
Degeneration change from higher to lower form
Etiology the cause(s) of a disease
Idiopathic disease of unknown case
Remission reduction or disappearance of the signs/ symptoms of a disease
Recurrent return of a disease after a period of remission
Morbidity illness rate
Mortality death rate
Prognosis recovering from injury or disease
Localized limited to a certain part of the body
Systemic/ generalized affecting the entire body
Occult hidden
Pathogen disease causing organism
Lesion area of abnormal damaged tissue
Sequelae a condition resulting from a disease
Pending patient is neither active nor inactive
Disposition final place patient was discharged
Discharge to leave, whether a patient leaving a hospital, or a fluid leaving the body
Prophylaxis attempt to prevent disease
Palliative relief of symptoms
Observation watching a patient's condition
Reassurance making patients feel safe and understood
Supportive Care physical, psychological, social, and spiritual support for patients and their families
Sterile free from microorganisms
Superior towards the top, above
Inferior towards the bottom, below
Transverse plane divides the superior and inferior halves
Sagittal plane divides the left and right halves
Coronal plane divides the front and back sides
Supine lying on the back with face and torso pointing up
Prone lying flat on the front, face down
Contralateral control each hemisphere of the brain controls the contralateral side of the body (left hemisphere controls he right side and vice versa)
Ipsilateral control affecting the same side of the body
Unilateral affecting one side of the body or organ
Bilateral affecting both sides or two of something
Dorsum the back or posterior side of the foot or hand
Palmar the palm or anterior side of the hand
Plantar the sole or anterior side of the foot
Clinic note a required form of documentation that describes a patient encounter
Consult note a report of detailing previous exam a patient recommendations
Emergency department note (EDN summary of patient's status during an emergency encounter
Admission summary documents reason why patient is being admitted for care
Discharge summary documents patient's care plan
Operative report document detailing what happened in the operating room
Daily hospital note/ progress note presents patient's latest information and daily clinical progress
Radiology report detailed report that describes results of imaging test
Pathology report report about a piece of tissue, blood, or organ that ahs been removed
Prescription instruction written for a patient to be provided medicine or treatment
Pre-up
Post-up
OR
PACU
ICU Intensive care unit
ER Emergency room
ECU extensor carpi ulnaris
L&D labor and delivery
Dx diagnosis
Hx history
Tx treatment
Px prescription
CC chief complaint
Created by: kayhun3437
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