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SOAP

Medical Terminology

TermDefinition
S = Subjective Subject to how a patient experiences and personally describes the problem, as well as personal and family medical history. Data includes - duration, quality, and any exacerbating or relieving factors.
O = Objective Data is comprised of the physical exam, any lab findings, and image studies performed.
A = Assessment After gathering all info, the provider formulates a logical analysis - a diagnosis, an identification of the problem, or a list of possibilities for the diagnosis (differential diagnosis).
P = Plan The provider formulates a course of action consistent with the assessment - treatment with a medication or procedure, or even collecting further data to help arrive at a more accurate diagnosis.
ACUTE just started recently, or a sharp, severe symptom
CHRONIC has been going on for a while now
EXACERBATION 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 non related to this specific problem
LETHARGIC a decrease in level of consciousness; generally, the patient is really sick
GENETIC/HEREDITARY runs in the family
ALERT able to answer questions; responsive; interactive objective
ORIENTED being aware of who they are, where they are, and the current time - if aware of all 3 they are "oriented x3" objective
MARKED it really stands out objective
UNREMARKABLE another way of saying normal objective
AUSCULTATION to listen objective
PERCUSSION to hit something and listen to the resulting sound or feel for the resulting vibration objective
PALPATION to feel objective
IMPRESSION another way of saying assessment assessment
DIAGNOSIS what the healthcare professional thinks the patient has assessment
DIFFERENTIAL DIAGNOSIS a list of conditions the patient may have based on the symptoms exhibited and the results of the exam assessment
BENIGN safe assessment
MALIGNANT dangerous; a problem assessment
DEGENERATION to be getting worse assessment
REMISSION to get better or improve assessment
IDIOPATHIC no known specific cause; it just happens assessment
LOCALIZED stays in a certain part of the body assessment
SYSTEMIC/GENERALIZED all over the body (or most of it) assessment
PROGNOSIS the chances for things getting better or worse assessment
OCCULT hidden assessment
LESION diseased tissue assessment
RECURRENT to have again assessment
SEQUELA a problem resulting from a disease or injury assessment
PENDING waiting for assessment
PATHOGEN the organism that causes a problem public health/assessment
MORBIDITY the risk for being sick public health/assessment
MORTALITY the rick for dying public health/assessment
ETIOLOGY the cause public health/assessment
DISPOSITION what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, ICU, normal hospital bed) plan
DISCHARGE literally means to unload; 1. to send home (to unload the patient from the healthcare setting to home) 2. fluid coming out of a part of the body (your body unloading a fluid) plan
PALLIATIVE treating symptoms, but not actually getting rid of the cause plan
OBSERVATION watch, keep and eye on plan
SUPPORTIVE CARE to treat symptoms and make the patient feel better plan
STERILE extremely clean plan
PROPHYLAXIS preventive treatment public health/plan
Created by: simlay1
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