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Medical terminology

terms and abbreviations

TermDefinition
Subjective How the medical issue is described by the patient, as well as personal and family medical histories.
Objective information consisting of a physical exam, lab results, and imaging studies
Assessment After compiling all the information gathered, trying to identify the problem, or a list of possible diagnosis
Plan Deciding how to treat the issue with medicine or procedure, or even collecting more data.
Anatomic position A position in which the human body is facing forward, palms out; used when describing directions on the body
Biltateral Both sides
Social History A history of behaviors that could impact a patient's health; e.g. smoking, drinking, drug use, sexual practices
PERRLA pupils are equal, round and reactive to the light and accommodation
CTA clear to auscultation (description of normal sounding lungs)
Discharge Summary Describes when and why the patient was admitted; documents a longer stay
Created by: hwilliams86
 

 



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