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MedTerm101

Flash Cards Ch. 2 Medical Terms

QuestionAnswer
How are the different sections of SOAP color coded? Subjective - Blue Objective - Red Assessment - Yellow Plan - Green
What is the definition of "Review of systems"? Description of individual body systems in order to discover any symptoms not directly related to the main problem.
What is the definition of "Social history"? A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health.
How may a "clinic note" be documented? Handwritten, dictated, or electronic. They may also involve circling of correct words or checking boxes on a template.
What does a "discharge summary" detail? When and why a patient was admitted to the hospital.
What does an "operative report" document in detail? Procedure that was performed, events that transpired, and the patient's outcome.
What does a radiology report note entail? A radiology report note explains the reason for ordering a radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist's notes.
A prescription note does not follow the SOAP note format because why? Because it is the plan.
What is the second line in a prescription marked SIG contain? SIG contains the patient's instructions.
The third line marked "dispense" tells the pharmacist what? How much medicine to give the patient.
What does SICU stand for? Surgical intensive care unit
What does PACU stand for? post-anesthesia care unit
What is the definition of "
Created by: sbrown349
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