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Health Records
| Term | Definition |
|---|---|
| EHR | Electronic Health Record |
| SOAP | subject, objective, assessment, plan |
| subjective | reason for visitation, problems patient is having with |
| objective | test reveals (lab tests or images) |
| assessment | analysis of subject and objective information |
| plan | course of action for patient (medication, surgery, further tests, etc.) |
| acute | occurs recently, sharp severe symptoms |
| chronic | problem that occurs for while |
| abrupt | occurs suddenly |
| febrile | has fever |
| afebrile | does not have fever |
| malaise | not feeling well |
| progressive | worsening of symptoms |
| exacerbation | worsening of a condition |
| symptom | what patient feels |
| noncontributory | patients symptom is not related to currennt problem |
| lethargic | decrease level in consciousness |
| genetic/hereditary | runs in the family |
| disposition | where the patients went (home, hospital, nursing home) |
| discharge | to send home, fluid coming out of a part of the body |
| prophylaxis | preventive treatment |
| palliative | relieve symptoms, but not cure |
| observation | to watch |
| reassurence | actions that make patient feel better |
| supportive care | treat symptoms to make patient feel better |
| sterile | extremely clean, germ-free conditions |
| alert | patient can answer questions, is responsive and interactive |
| oriented | patient knows who they are, where they are, and what time is it |
| auscultation | to listen |
| percussion | to hit or strike and then listen for sound, returned sound indicated condition |
| palpation | to feel something |
| unremarkable | normal |
| marked | stands out |
| impression | another word for assessment |
| diagnosis | using subjective and objective to determine plan condition |
| differential diagnosis | cannot yet determine patients condition |
| benign | not cancerous |
| malignant | cancerous |
| degenaration | getting worse |
| etiology | cause of |
| idiopathic | no known cause |
| remission | no longer having the symptoms |
| recurrent | to have again |
| morbidity | risk of being sick or diseased |
| mortality | risk of dying |
| prognosis | chance of getting better or worse |
| localized | one area |
| systematic/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 |
Created by:
cmoranramirez
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