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Study week 1
Chapter 2
| Term | Definition |
|---|---|
| S”soap” | Subject, patient’s personal experience with their problem in their family medical history |
| A”soap” | Assessment, diagnosis and to identify the problem or a list of possible diagnosis’s |
| O”soap” | Objective, data found during physical exam or labs imaging or other data collected. |
| P”soap” | Plan,the course of action, what needs to happen such as collecting more data to be closer to a diagnosis |
| Bilateral | Both sides |
| Contralateral | Opposite sides |
| Ipsilateral | Same side |
| Unilateral | One side of body |
| Transverse | Divided from top to bottom |
| Dorsal | back |
| Prone | Lying face down on belly |
| Coronal | Divided from front and back |
| Supine | Lying on back |
| Sagittal | Divided from left and right |
| Pathology report | This report notes the reason for the study what was seen in details in the assessment |
| Radiology report | Explains the reason for the order in the radiologic imaging how the imaging was performed and what was seen during the imaging and the reviewing of the radiologist. |
| Hospital note/progress note | This is a daily note documenting the visits t and the subject of these daily hospital notes usually are about the patient’s condition and if it has changed |
| Operative report | This report is usually done after surgery. It states the detail of the procedure that was performed and the outcome of the surgery and a discharge summary and then the beginning of the note is the diagnosis. |
| Discharge summary | The summary explains when and why the patient was seen how they felt when they entered and how they felt when they left and explains what happens during the day and what the patient should follow up after leaving |
| Admission summary | This is a summary about how the patient entered and their symptoms. This will have medical history and explain a physical exam that was performed. |
| Emergency department note | This note will have the patient’s history and it’ll show what labs or course of action was taken in the Emergency department. |
| Consult note | This note would be done by specialist. This will be the opinion of the specialist to the primary care |
| Clinic note | This note is by a healthcare professional that had seen that patient in the office setting they can be handwritten electronic or could simply circle correct words or check boxes to fit. The patients visit needs this follows the soap method. |
| AC | Before meals |
| BID | Twice a day |
| PC | After meals |
| PRN | As needed |
| QD | Daily |
| QHS | At night |
| QID | Four times a day |
| TID | Three times a day |
Created by:
athomas578
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