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Ch.2
Intro. to Health Records
| term | definition |
|---|---|
| SOAP | Subjective: What the patient says Objective: What the tests reveal Assessment: Analysis of subject & Objective info; performed by provider. Plan: course of action |
| G.S.T Acute vs. Chronic | Occurs recently/ sharp sever symptoms, problem that occurs for a while |
| Abrupt | occurs suddenly |
| Febrile vs. Afebrile | a fever, does not have a fever |
| Malaise | not feeling well |
| Progressive vs. Exacerbation | worsening of symptoms, worsening of condition |
| Symptoms | what the patient feels |
| Noncontributor | patient's symptom is not related to current problem |
| Lethargic | decrease in level of consciousness |
| Genetic/Hereditary | runs in the family |
| G.A.T Impression | another word for assessment |
| Diagnosis | subjective & objective data to determine patient's condition |
| Differential Diagnosis | subjective & objective data, the provider cannot yet determine the diagnosis |
| Benign vs. Malignant | not cancerous, cancerous |
| Degeneration | getting worse |
| Etiology vs. Idiopathic | the cause, no known cause |
| Remission | no longer having the symptoms of a disease (refer to cancer) |
| Recurrent | to have again |
| Morbidity | risk of being sick or diseased |
| Mortality | risk of dying |
| Prognosis | chance of getting better or worse |
| Localized vs. systemic/ generalized | one area, over lg area or body system |
| Occult | hidden |
| Pathogen | organism that causes the disease |
| Lesion | diseased tissue |
| Sequela | result of disease or injury |
| Pending | waiting for |
| G.P.T Disposition | where patient went to conclusion of the visit |
| Discharge | sent home or fluid coming out of a part of the body |
| Prophylaxis | preventative treatment |
| Palliative | relieve symptoms, but not cure |
| Observation | to watch |
| Reassurance | actions that make the patient feel better |
| Supportive care | treat symptoms to make the patient feel better |
| Sterile | extremely clean, germ-free conditions |
| Body Planes & Orientation R & L | Right and left side of the body |
| Midline | going straight down |
| Medial & Lateral | towards to inside & away from central |
| Proximal & Distal | upward limbs & downward limbs |
| Anterior (Ventral) & Posterior (Dorsal) | standing face forward, arms at sides with palm forward |
| Cranial & Caudal | head, tail (describes area of the trunk/ head/ neck) |
| Supine & Prone | lay on back looking up, lying on belly |
| Contralateral control | opposite side |
| Ipsilateral control | same side |
| L & R Hemisphere's | Left hemisphere to right hand, Right hemisphere to left hand |
| Unllalteral | one side |
| Bilateral | both sides |
| Dorsum & Palmar & Plantar | Top of hand/ foot, palmar is palm of hand, Plantar sole of foot |
| H. P. Physician | health care provider who graduated medical school |
| Pediatrician | specialty caring for children |
| surgeon | treat patients surgically |
| anesthesiologist | pain sedation and pain control |
| (PA) Physician assistant | midlevel who works under supervision |
| (NP) Nurse Practitioner | midlevel who works under supervision |
| (EMT) Emergency Medical Technician | Emergency care for patients before and/ or during transportation |
| Speech Therapist | evaluating and treating problems with speech/ swallowing |
| Occupational Therapist | treating problems with performing daily activities somewhere |
| Physical Therapist | Evaluating and treating physical impairments including disabilities or recovery from an injury |
| Respiratory Therapist | treating patient's respiratory issues under guidance |
| Dietician | Evaluating the nutritional status of patient and develop appropriate diet plan |
| (LPN) Licensed practical nurse | Trained and certified to provide basic care to a patient |
| (LVN) Licensed vocational nurse | Trained and certified to provide basic care to a patient |
| (RN) Registered nurse | Advanced level nurse; assists with patient care planning and patient education |
| (MA) Medical Assistant | trained in basic administrative and clinical tasks under guidance |
| Lab. & Pathology Pathologist | Evaluating the cause and effect of disease and in laboratory medicine |
| medical laboratory technician | performing laboratory testing on bodily fluids |
| Phlebotomist | removal of blood from the body for diagnostic or therapeutic purposes |
| Radiology Radiologist | evaluating images of the body to diagnose illness or injury |
| Radiology Technician | Perform radiologic testing or administer radiation therapy under direction of provider |
| Ultrasonographic | Performing ultrasound imaging on patient |
| Pharmacy Pharmacist | Preparing and dispensing medicine |
| Pharmacy technician | assist a pharmacist with pharmacy-related tasks |
| Clinical Support Patient Service Coordinator | administrative tasks and coordinates patient care |
| Medical Transcriptionist | converting the voice-recorded dictations of providers into text format |
| Abbreviations- Areas of Health Care Facility Pre-Op | before surgery |
| OR | Operating Room |
| PACU | Post Anesthesia Care Unit |
| Post-op | after surgery |
| ICU | Intensive Care Unit |
| CCU | Coronary (heart) Care Unit |
| SICU | Surgical Intensive Care Unit |
| PICU | Pediatric Intensive Care unit |
| NICU | Neonatal (newborn) Intensive Care Unit |
| ER | Emergency Room |
| ED | Emergency Department |
| ECU | Emergency Care Unit |
| L&D | Labor and delivery |
| Abbreviations - Symbols circle with arrow | male: a man carrying a spear |
| circle with cross | female: woman holding a mirror with a handle |
| (R) | right |
| (L) | left |
| (B) | Bilateral (both sides) |
| arrow up | increased |
| arrow down | decreased |
| Abbreviations - Common on Health Records VS (Vital Signs) are made up of | HR (heart rate), RR (respiratory rate), BP (Blood pressure), T (temperature) |
| HT | height |
| Wt | weight |
| BMI | body mass index |
| I/O | input/output - monitors the amount of fluid taken in/ amount of fluid put out |
| Dx | diagnosis |
| DDX | differential diagnosis |
| Tx | treatment |
| Rx | presciption |
| Hx | history |
| PMHx | past medical history |
| FHx | family history of |
| H&P | history and physical |
| CC | patient's chief complaint |
| HPI | history of present illness |
| ROS | review of systems |
| PE | physical exam |
| PCP | primary care provider |
| NKDA | no known drug allergies |
| Pt | patient |
| y/o | years old |
| h/o | history of |
| f/u | follow up |
| Abbreviations - Used for Symptoms/ Exam PERRLA | Pupil equal, round, and reactive to light and accomodation |
| NOS | Not otherwise Specified |
| RRR | Regular rate and rhythm |
| CTA | Clear to auscultation |
| A&O | Alert and Oriented |
| NAD | No acute distress |
| Abbreviations - W/ Orders & Administering PO | Per Os (by mouth) |
| IV | Intravenous |
| SC | Subcutaneous |
| CVL | Central Venous Line |
| IM | Intramuscular |
| PR | Per Rectum (anal) |
| NPO | Nil Per Os (nothing by mouth) |
| Abbreviations - Timing & Frequency prn | as needed |
| QID | four times a day |
| QD | once a day |
| AC | before meals |
| TID | three times a day |
| BID | twice a day |
| PC | after meals |
| QHS | at night/ bedtime |
| Superior & Inferior | above, below |
| Coronal plane | divides body front to back |
| Sagittal plane | right and left |
| transverse plane | top and bottom |
| G.O.T Things that are seen | -alert -oriented |
| Things that are heard | - auscultation -percussion |
| Things that are felt | -palpation |
| descriptions of what is observed | -unremarkable -marked |
Created by:
aleyee