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Chapter 2
Intro to Health Records
| Term | Definition |
|---|---|
| ACUTE | Occurs recently, or sharp severe symptoms |
| CHRONIC | A problem that occurs for a while |
| ABRUPT | Occurs suddenly |
| FEBRILE | Has a fever |
| AFEBRILE | Does not have a fever |
| MALAISE | Not feeling well |
| PROGRESSIVE | Worsening of symptoms |
| EXACERBATION | Worsening of condition |
| SYMPTOM | What the patient feels |
| NONCONTRIBUTORY | Patient's symptom is not related t the current problem |
| LETHARGIC | A decrease in level of consciousness |
| GENETIC | It runs in the family |
| HEREDITARY | It runs in the family |
| ALERT | Patient can answer questions; responsive, interactive |
| ORIENTED | Patient knows who they are, where they are, and what time it is (current date and time) |
| AUSCULTATION | To listen (usually with a stethoscope) |
| PERCUSSION | To hit or strike and then listen for a sound; the returned sound indicates the condition of the body |
| PALPATION | To feel something; how something feels can indicate its condition, be it normal or abnormal |
| UNREMARKABLE | Normal |
| MARKED | It stands out |
| IMPRESSION | Another word for assessment |
| DIAGNOSIS | Using the subjective and objective data to determine the patient's condition |
| DIFFERENTIAL DIAGNOSIS | Based don the subjective and objective data, the health care professional cannot yet determine the diagnosis |
| BENIGN | Not cancerous |
| MELIGNANT | Cancerous |
| DEGENERATION | Getting worse |
| ETIOLOGY | The cause |
| IDIOPATHIC | No known cause |
| REMISSION | No longer having the symptoms of a disease |
| RECURRENT | To have again |
| MORBIDITY | Risk of being sick or diseased |
| MORTALITY | Risk of dying |
| PROGNOSIS | Chances of getting better or worse |
| LOCALIZED | One area |
| SYSTEMIC/GENERALIZED | Over a large area or body system |
| OCCULT | Hidden |
| PATHOGEN | Organism that causes the disease |
| LESION | Diseased tissue |
| SEQUELA | Result of disease or injury |
| PENDING | Waiting for |
| DISPOSITION | Where the patient went at the conclusion of the visit |
| DISCHARGE | To send home/Fluid coming out of a body part |
| PROPHYLAXIS | Preventative treatment |
| PALLIATIVE | Relieve symptoms, but not cure |
| OBSERVATION | To watch |
| REASSURANCE | Actions that make a patient feel better |
| SUPPORTIVE CARE | Treat symptoms to make the patient feel better |
| STERILE | Extremely clean, germ-free conditions |
| ANATOMICAL POSITION | A person standing face forward, arms at the side with palms forward |
| PROXIMAL | Refers to the upper extremities |
| DISTAL | Refers to the lower extremities |
| LATERAL | Describes the relationship to the center |
| MEDIAL | Describes the relationship to the center |
| VENTRAL/ANTRAL/ANTERIOR | All mean front when referring to the human |
| DORSAL/POSTERIOR | All mean back when referring to the human |
| SUPERIOR | Above |
| INFERIOR | Below |
| CRANIAL | Head |
| CAUDAL | Tail |
| SUPINE | Lying on back; patient looking up |
| PRONE | Lying on the belly |
| UNILATERAL | One side |
| BILATERAL | Two sides |
| PLANTAR | Refers to the sole of the foot |
| DORSUM | Refers to the top/back something, such as the hand or foot |
| PALMER | Refers to the palm of the hand |
| IPSILATERAL | Same side |
| CONTRALATERAL | Opposite side |
| CORONAL PLANE | Divides the body into anterior and posterior sides (front and back) |
| SAGITTAL PLANE | Divides the body into right and left sides |
| TRANSVERSE PLANE | Divides the body into superior and inferior (top and bottom) |
| PHYSICIAN | A skilled health care provider who attended and graduated medical school |
| 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 |
| PHYSICIAN ASSISTANT (PA) | A midlevel health care provider who works under the license of a supervising physician; requires postgraduation training |
| NURSE PRACTITIONER (NP) | A nurse with postgraduate training that serve 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 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, work, or school |
| 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 | Trained and certified to provide basic care to a patient |
| REGISTERED NURSED | 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 | 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 |
| PHELBOTOMIST | Trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| 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 |
| ULTRASONAGRAPHER | 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 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, sexual practices that can impact health |
Created by:
Nisha97