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Med Term

medical terminology flash cards

TermDefinition
SOAP Acronym for: Subjective Objective Assessment Plan
Subjective part of SOAP Description of the problem in the patient's own words along with personal and family histories.
Objective part of SOAP The investigative process of collecting data including physical examination, laboratory findings, and imaging studies done at the appointment.
Assessment part of SOAP After all information is gathered, the medical professional will make a diagnosis or differential diagnosis for the patient's complaints.
Plan part of SOAP When the medical professional makes a diagnosis, they will plan a treatment using medication, procedures, surgery, or will request to collect more information if needed.
Body Planes: Sagittal Coronal Transverse Plane that divides the body into Right and Left halves Plane dividing the body into front and back sections Plane that divides the body into top and bottom in the middle
Abbreviations Associated with Orders and Administering Medication PO NPO PR PICC Per Os (by mouth) Nil Per Os (nothing by mouth) Per Rectum (anal) Peripherally Inserted Central Catheter
Timing Abbreviations: AC PC ad lib Before meals (ante cibum meaning "before food") After meals (post cibum meaning "after food") As desired
Common Healthcare Record Abbreviations: DDx HEENT CTA Differential Diagnosis Head, Eyes, Ears, Nose, and Throat Clear To Auscultation (normal sounding lungs)
Different Types of Health Records (10 total) Clinic & Consult Notes Emergency Dept Note Admission Summary Discharge Summary Operative Report Daily Hospital/Prog Note Radiology Report Pathology Report
Created by: beachgrl
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