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Ch2. Health Records
Medical Terms and Abbreviations
Term | Definition |
---|---|
exacerbation ( eks-AS-er-BAY-shun ) | it is getting worse |
PACU | POST-ANESTHESIA CARE UNIT |
QHS | at night, from the Latin phrase quaque hora somni, which means " each night at the hour of sleep " |
S O A P ( blue, red, yellow, green ) | Subjective, Objective, Assessment, Plan |
lethargic ( lah-THAR-jik ) | a decrease in level of consciousness ; in a medical record, this is generally an indication that the patient is really sick |
proximal ( PRAWK-sih-mal ) | closer into the center proximal & approximate come from the same word & mean close |
prophylaxis ( proh-fin-LAK-sis ) | preventive treatment |
SC | subcutaneous ( under the skin ) |
WOWN | well developed, well nourished ( the patient is growing or has grown appropriately and does not appear to be malnourished ) |
A = ASSESSMENT | the analysis of the Subjective and Objective information performed by the health care provider. Could include a diagnosis, differential diagnosis, identification of a problem, or offer other opinions like severity and chances of improvement |