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Chapter 2 Flash Card

Introduction to Health Records

TermDefinition
subjective patient experience
objective patient's physical exam, labatory finding and imaging studies
assessment diagnosis
plan course of action
SOAP subjective, objective, assessment, plan
acute it just started recently or a sharp, severe symptom
chronic it has been going on for a while now
exacerbation it 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 not related to this specific problem
lethargic a decrease of level of consciousness in a medical record, this is generally an indication that he patient is really sick
genetic/hereditary it runs in the family
alert able to answer questions; responsive; interactive
oriented being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented x3"
marked is really stands out
unremarkable another way of saying normal
auscultation to listen
percussion to hit something and listen to the resulting sound or feel for the resulting vibrations, drums are percussion instrument
palpation to feel
impression another way of saying assessment
diagnosis what the health care professional thinks the patient has
differential diagnois a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
benign safe
malignant dangerous; a problem
degeneration to be getting worse
Created by: janaes
 

 



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