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Med Term 1

TermDefinition
Combining form: cephal/o Meaning: head ex: cephalic - pertaining to the head
SOAP Note: consistent organizational pattern/layout. thought process of providers. S: Subjective; Pts experience O: Objective; Pts PE, labs + imaging findings A: Assessment; identifying dx P: Plan; course of action
Distal (dis-tal) further away from center distal and distant come from the same word and mean far
Ipsilateral (IP-sih-LAT-eh-ral) same side of body ex: Left Upper Extremity / Left Lower Extremity
Contralateral (KON-trah-LAT-er-ral) opposite side of body ex: Left Upper Extremity / Right Upper Extremity
Review of Systems (ROS) description of pts body systems, used to discover any symptoms not directly related to main (presentation) problem
Daily Hospital Note/Progress Note: Documenting daily hospital visit (inpatient health care facility) SOAP Note with unique layout: SO A/P S: focuses on how Pts condition has changed since previous note A: sometimes includes a differential dx (DDx)
Pt patient
PE physical exam
Dx diagnosis
Combining form: cyt/o Meaning: cell cytology = study of cells
Created by: alockhart9
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