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Chpt. 2 HLHS101

Health Records

TermDefinition
Alert (O) patient can answer questions
Percussion (O) to hit or strike and then listen for a sound; the returned sound indicates the condition of the body
SOAP Subjective - what the patient says Objective - what the test reveals Assessment - what the analysis of both subjective & objective information P - plan; course of action for the patient
Progressive (S) worsening of SYMPTOMS
Exacerbation (S) worsening of a CONDITION
Impression (A) another word for assessment
Diagnosis (A) using the subjective and objective data to determine the patients condition
Disposition (P) where the patient went after the conclusion of the visit ex - home, hospital
Prophylaxis (P) preventative treatment
Palliative (P) relieve symptoms, NOT cure
Created by: Wamador
 

 



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