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HLHS 101 ch.2

medical terminology chapter 2

TermDefinition
SOAP S = Subjective: what the patient says O = Objective: what the tests reveal A = Assessment: the analysis of the subjective and objective information; performed by the health care provider P = Plan: the course of action for the patient
Chief complaint The main reason for the patient’s visit
I/O input/output
DDx differential diagnosis
HPI history of present illness
NKDA no known drug allergies
Tx treatment
medical transcriptionist trained in converting the voice-recorded dictations of health care providers into text format
VS (vital signs) are made up of HR (heart rate), RR (respiratory rate), BP (blood pressure), and T (temperature)
H&P history and physical
Created by: krhodes2124
 

 



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