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Medical Terminology
Chapter 2
| Term | Definition |
|---|---|
| What is the the acronym SOAP stand for | Subjective, Objective, Assessment, Plan |
| What is documented in the Subjective (S) section | What the patient says |
| What is documented in the Objective (O) section | What the test reveal |
| What is documented in the Assessment (A) section | The analysis of the subjective and objective information; Performed by the health care provider |
| What is documented in the Plan (P) section | The course of action for the patient |
| What all does a patients health record contain | Previous Illness and Treatments Continuing Medical Problems History of family illnesses Current medications |
| Physician | Skilled health care provider who attended and graduated medical school |
| Pediatrician | physician with special training in caring for children |
| surgeon | Physician qualified to treat patients surgically |
| Anesthesiologist | Physician with special training in pain sedation and pain control |
| Physician Assistant (PA) | Midlevel health care provider who works under the licenses of a supervising physician |
| Nurse Practitioner (NP) | Nurse with post graduate training that serves as a midlevel health care provider; works under a license of a supervising physician |
| Emergency Medical Technician (EMT) | |
| Speech Therapist | Specially trained in evaluating and treating problems with speech and/or swallowing |
| Occupational Therapist | Specially trained in evaluating and treating problems with performing daily activities at home, school or work |
| Physical Therapist | Specially trained in evaluating and treating physical impairments including disabilities or recovering from an injury |
| Respiratory Therapist | Specially trained in treating patient's respiratory issues under the guidance of a health care provider |
| Dietician | Specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan |
| Licensed Practical Nursing (LPN) | Trained and certified to provide basic care to a patient |
| Registered Nurse | Advanced level nurse who has completed an associates or bachelors degree; often assist with patient care planning and patient education |
| Medical Assistant | Trained to carry out basic |
| Pathologist | Physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| Medical Laboratory Technician | Trained in performing laboratory testing on bodily fluids |
| Phlebotomist | Trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| Radiologist | Physician specially trained in evaluating images of the body to diagnose illness or injury |
| Radiology Technician | Trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonographer | trained in performing ultrasound imaging on a patient |
| Pharmacist | Trained and licensed in preparing and dispending medicine |
| Pharmacy Technician | Trained to assist a pharmacist with pharmacy related task |
| Patient Service Coordinator | Handles administrative task and coordinates patient care |
| Medical Transcriptionist | trained in converting the voice-recorded dictations of health care providers into text format |
| Chief Complaint | Main reason for a patients visit |
| History of present illness | story of the patients problem |
| Review of symptoms | Description of individual body systems in order to discover any symptoms not directly related to the main problem |
| Past medical history | Other significant past illness, like high blood pressure, asthma, or diabetes |
| Past surgical history | Any of the patients past surgeries |
| Family History | Any significant illness that run in the patients family |
| Social History | Record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health |
| What are included in the Vital Sign section | Heart Rate (HR) Respiratory Rate (RR) Blood Pressure (BP) Temperature (T) |
| What is the abbreviation Ht | Height |
| What is the abbreviation Wt | Weight |
| What does BMI stand for | Body Mass Index |
| What is the abbreviation for Input/Output | I/O |
| What is the Abbreviation for diagnosis | Dx |
| What is the abbreviation for differential diagnosis | DDx |
| What is the abbreviation for treatment | Tx |
| What is the abbreviation for prescription | Rx |
| What is the abbreviation for history | Hx |
| What is the abbreviation for History and physical | H&P |
| What is the abbreviation Chief Complaint | CC |
| What is the History of Present Illness | HPI |
| What is the Abbreviation for Physical Exam | PE |
| What is the Abbreviation for Primary Care Provider | PCP |
| What is the abbreviation for No Known Drug Allergies | NKDA |
| What is the abbreviation for patient | Pt |
| What is the abbreviation for years old | y/o |
| What is the abbreviation for history of | h/o |
| What is the abbreviation for follow up | f/u |
| What does the abbreviation PERRLA stand for | Pupils Equal Round and reactive to light and accommodation |
| What does the abbreviation NOS stand for | Not Otherwise specified |
| What does the abbreviation RRR stand for | Regular Rate and Rhythm |
| What does the abbreviation CTA stand for | Clear to auscultation |
| What does the abbreviation A&O stand for | Alert and Oriented |
| What does the abbreviation NAD stand for | No acute distress |
| What does the abbreviation PO stand for | Per OS ( By Mouth) |
| What does the abbreviation IV stand for | Intravenous |
| What does the abbreviation SC stand for | Subcutaneous |
| What does the abbreviation CVL stand for | Central Venous Line |
| What does the abbreviation IM stand for | intramuscular |
| What does the abbreviation PR stand for | Per Rectum (Anal) |
| What does the abbreviation NPO stand for | Nil per os ( Nothing by mouth) |
| What does the abbreviation PRN stand for | As needed |
| What does the abbreviation QID stand for | Four times a day |
| What does the abbreviation QD stand for | Every Day |
| What does the abbreviation AC stand for | Before meals |
| What does the abbreviation TID stand for | Three Times a day |
| What does the abbreviation BID stand for | Two times a day |
| What does the abbreviation PC stand for | After meals |
| What does the abbreviation QHS stand for | At night |
Created by:
Luke.fritzinger
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