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Medical Terminology

Introduction to Health Records

TermDefinition
SOAP an acronym for the four different types of information documented by health care providers in a medical note. S = Subjective: what the patient says O = Objective: what the tests reveal A = Assessment: the analysis of the subjective & objective informa
HPI History of Present Illness
Anesthesiologist A physician with special training in pain sedation and pain control
Plantar Refers to the sole or bottom of the foot.
Unilateral Refers to one side of the body
NKDA No Known Drug Allergies
Supine Position The patient is lying on their back and is looking up
Prophylaxis Refers to steps/actions taken to prevent disease i.e. Vaccines, checkups
NPO Nothing by Mouth
Sequelae The result of disease or injury i.e. pneumonia due to flu
Created by: BrooksGJ
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