the analysis of the subjective and objective information; performed by health care provider

the course of action for the patient

been going on for a while; sub.

something the patient feels; sub.

not related to this specific problem; sub.

decrease in level of consciousness; sub.

able to answer the questions; responsive; interactive; obj.

being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all 3 is ".........x3"; obj.

another way of saying normal; obj.

to hit something and listen to the resulting sound or feel for the resulting vibration; drums are an example of this term; obj.

another way of saying assessment; ass.

what the healthcare professional thinks the patient has; ass.

Differential Diagnosis

a list of conditions the patient may have based on the symptoms exhibited and the results of the exam; ass.

to get better or improve; most often used when discussing cancer; does not mean cure; ass.

no known specific cause; it just happens; ass.

stays in a certain part of the body; ass.

all over the body(or most of it); ass.

the chances for things getting better or worse; ass.

a problem resulting from a disease or injury; ass.

the organism that causes the problem; ass.

what happened at the end of the visit; where the patient went(home, ICU, normal hospital bed); plan.

to unload: 1. to send home (patient from hospital to home). 2. fluid coming out of a part of the body; plan.

treating the symptoms, but not actually ridding the cause; plan.

to tell the patient that the problem is not serious/dangerous; plan.

to treat the symptoms and make the patient feel better; plan.

extremely clean, germ-free conditions; especially important during medical procedures and surgery; plan.

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Ch. 2 - SOAP Terms

Health Record Terms

Term	Definition
Subjective	what the patient says
Objective	what the tests reveal
Assessment	the analysis of the subjective and objective information; performed by health care provider
Plan	the course of action for the patient
Acute	just started recently; sub.
Chronic	been going on for a while; sub.
Abrupt	all of a sudden; sub.
Febrile	to have a fever; sub.
Afebrile	to not have a fever; sub.
Malaise	not feeling well; sub.
Progressive	more and more each day; sub.
Exacerbation	it is getting worse; sub.
Symptom	something the patient feels; sub.
Noncontributory	not related to this specific problem; sub.
Lethargic	decrease in level of consciousness; sub.
Genetic/Hereditary	it runs in the family; sub.
Alert	able to answer the questions; responsive; interactive; obj.
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 3 is ".........x3"; obj.
Marked	it really stands out; obj.
Unremarkable	another way of saying normal; obj.
Auscultation	to listen; obj.
Percussion	to hit something and listen to the resulting sound or feel for the resulting vibration; drums are an example of this term; obj.
Palpation	to feel; obj.
Impression	another way of saying assessment; ass.
Diagnosis	what the healthcare professional thinks the patient has; ass.
Differential Diagnosis	a list of conditions the patient may have based on the symptoms exhibited and the results of the exam; ass.
Benign	safe; ass.
Malignant	dangerous; ass.
Degeneration	to be getting worse; ass.
Remission	to get better or improve; most often used when discussing cancer; does not mean cure; ass.
Idiopathic	no known specific cause; it just happens; ass.
Localized	stays in a certain part of the body; ass.
Systemic/Generic	all over the body(or most of it); ass.
Prognosis	the chances for things getting better or worse; ass.
Occult	hidden; ass.
Lesion	diseased tissue; ass.
Recurrent	to have again; ass.
Sequela	a problem resulting from a disease or injury; ass.
Pending	waiting for; ass.
Pathogen	the organism that causes the problem; ass.
Morbidity	the risk for being sick; ass.
Mortality	the risk for dying; ass.
Etiology	the cause; ass.
Disposition	what happened at the end of the visit; where the patient went(home, ICU, normal hospital bed); plan.
Discharge	to unload: 1. to send home (patient from hospital to home). 2. fluid coming out of a part of the body; plan.
Palliative	treating the symptoms, but not actually ridding the cause; plan.
Observation	watch, keep an eye out; plan.
Reassurance	to tell the patient that the problem is not serious/dangerous; plan.
Supportive Care	to treat the symptoms and make the patient feel better; plan.
Sterile	extremely clean, germ-free conditions; especially important during medical procedures and surgery; plan.
Prophylaxis	preventative treatment; plan.
Proximal	closer to the center (of the body).
Distal	farther away from the center (of the body).
Lateral	out to the side (of the body).
Medial	toward the middle (of the body).
Ventral/Antral/Anterior	the front (of the body).
Dorsal/Posterior	the back (of the body).
Cranial	toward the top (of the head).
Caudal	toward the bottom (of the head).
Superior	above (the body).
Inferior	below (the body).
Prone	lying down on belly.
Supine	lying down on back.
Contralateral	opposite side (of the body).
Ipsilateral	same side (of the body).
Unilateral	one side (of the body).
Bilateral	both sides (of the body).
Dorsum	the top of the hand or foot.
Plantar	the sole of the foot.
Palmar	the palm of the hand.
Sagittal	divides the body along a hypothetical plane from right to left.
Coronal	divides the body along a hypothetical plane from front to back.
Transverse	divides the body from top to bottom.
Physician	a skilled health care provider.
Pediatrician	a physician with special training in caring for children.
Surgeon	a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure.
Anesthesiologist	a physician with special training in pain sedation and pain control.
Epidemiologist	a specialist in the study of the causes and distribution of diseases in populations and the use of this data to enhance public health.
Physician Assistant (PA)	a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training.
Nurse Practitioner (NP)	a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician.
Emergency Medical Technician (EMT)	specially trained in the emergency care of a patient before and/or during transport to medical facility.
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 recovery 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 Nurse (LPN)/Licensed Vocational Nurse (LVN)	trained and certified to provide basic care to patient.
Registered Nurse (RN)	an advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education.
Medical Assistant (MA)	trained to carry out basic administrative and clinical tasks under the guidance of a health care provider.
Pathologist	a 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 purposed.
Radiologist	a 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 dispensing medicine.
Pharmacy Technician	trained to assist a pharmacist with pharmacy-related tasks.
Patient Service Coordinator	handles administrative tasks and coordinates patient care.
Medical Transcriptionist	trained in converting the voice=recorded dictations of health care providers into text format.
Chief Complaint	the main reason for the patient's visit.
History of Present Illness	the story of the patient's problem.
Review of Systems	description of individual body systems in order to discover any symptoms not directly related to the main problem.
Past Medical History	other significant past illnesses, like high blood pressure, asthma, or diabetes.
Past Surgical History	any of the patient's past surgeries.
Family History	any significant illnesses that run in the patient's family.
Social History	a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health.
Clinic Note	these can be handwritten, dictated, or electronic; always follow SOAP method.
Consult Note	from a visit to a specialist or consultant and can take two general types of approaches; most common is similar to the clinic note; may come in letter form to the primary care provider.
Emergence Department Note	patient medical history, as its critical to get patient's past to get a correct current diagnosis; explains what happened to the patient during their stay in the ED; contained a mixture of any completed diagnostic tests, patient assessment, and a plan.
Admission Summary	usually thorough notes that are very heavy on the subjective and objective parts; assembles all the facts in one place.
Discharge Summary	details when and why a patient was admitted, including how the patient felt, what happened during the visit, and what kind of follow-up they will have; may have diagnoses first (breaking SOAP method); after a longer stay in the hospital.
Operative Report	completed by the surgeon; documents in detail the procedure that was performed, the events that transpired during the surgery, and the patient's outcome from the surgery; contains a discharge summary with diagnosis at the beginning.
Daily Hospital Note/Progress Note	primarily composed of subjective notes; taken daily; focuses on how the patient's condition has changed since the previous note.
Radiology Report	explains the reason for ordering a radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist's assessment.
Pathology Report	mirrors the same style as the radiology note; mentions the reason for the study, what was seen in detail, and the assessment.
Prescription	doesn't follow SOAP because it is the plan; line 1: name & strength of meds. line 2: "sig"; patient's instructions. line 3: "dispense"; how much meds to patient. line 4: how many refills available. Health care providers signature at the end.
CCU	coronary care unit.
ECU	emergency care unit.
ER	emergency room.
ED	emergency department.
ICU	intensive care unit.
PICU	pediatric intensive care unit.
NICU	neonatal intensive care unit.
SICU	surgical intensive care unit.
PACU	post-anesthesia care unit.
L&D	labor and delivery.
OR	operating room.
post-OP	after surgery.
pre-OP	before surgery.
VS	vital signs.
T	temperature.
BP	blood pressure.
HR	heart rate.
RR	respiratory rate.
Ht	height.
Wt	weight.
BMI	body mass index (measurement of body fat based on height and weight).
I/O	intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output).
Dx	diagnosis.
DDx	differential diagnosis.
Tx	treatment.
Rx	prescription
H&P	history and physical.
Hx	history.
CC	chief complaint.
HPI	history of present illness.
ROS	review of systems (anything else not directly related to the CC).
PMHx	past medical history.
FHx	family history.
NKDA	no known drug allergies.
PE	physical exam.
Pt	patient.
y/o	years old.
h/o	history of.
PCP	primary care provider.
f/u	follow up.
SOB/SOA	shortness of breath/shortness of air.
HEENT	head, eyes, ears, nose, and throat.
PERRLA	pupils are equal, round, and reactive to light and accommodation.
NAD	no acute distress (the patient does not display any intense symptoms).
CV	cardiovascular.
RRR	regular rate and rhythm (description of normal heart on exam).
CTA	clear to auscultation (description of normal-sounding lungs).
WDWN	well developed, well nourished (patient is growing or has grown appropriately and does not appear to be malnourished).
A&O	alert and oriented (patient can answer questions and is aware of what's going on).
WNL	within normal limits.
NOS	not otherwise specified.
NEC	not elsewhere classified.
PO	per os (by mouth).
NPO	nil per os (nothing by mouth).
PR	per rectum (anal).
IM	intramuscular.
SC	subcutaneous (under the skin).
IV	intravenous.
CVL	central venous line.
PICC	peripherally inserted central catheter.
Sig	instructions short for signa, from Latin, for "label".
BID	twice daily; bis in die - "two in a day".
TID	three times daily; ter in die - "three in a day".
Q	every x; ex: Q4hr means every 4 hrs.
QD	daily; quaque die - "each day".
QID	four times daily; quater in die - "four in a day".
QHS	at night; quaque hora somni - "each night at the hour of sleep".
AC	before meals; ante cibum - "before food".
PC	after meals; post cibum - "after food".
prn	as needed; per re nata - "as the need arises".
ad lib	as desired.

Created by: emigre

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