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MA Notes
| Term | Definition |
|---|---|
| Chief Complaint | Primary reason for office visit |
| Medication Reconciliation | Comparing patient's list of medications to the medical record as a safety measure to reduce the risk of improperly prescribing an incorrect or contraindicated prescription. |
| Objective Information | information that can be observed of measured |
| Patient Health Questionnaire-2 (PHQ-2) | Focuses on the patient's frequency of depressed mood over two weeks |
| Patient Health Questionnaire-9 (PHQ-9) | comes after (PHQ-2) Asks additional questions to assess if the patient meets the criteria for a depressive disorder diagnosis |
| GAD-7 Questionnaire | Used for general anxiety and used to screen patients for anxiety |
| Auscultation | Listening with a stethescope |
| Systolic | Measurement of force while the heart is contracting; Top bp number |
| Diastolic | Measurement of force while the heart is relaxing; Bottom bp number |
| Expected Blood Pressure - Older than 12yrs | Systolic:110 - 130 , Diastolic: 65-80 |
| Expected Blood Pressure - 6 to 12yrs | Systolic:100-120, Diastolic:60-75 |
| Expected Blood Pressure - 3 to 6yrs | Systolic:95-110, Diastolic:60-75 |
| Expected Blood Pressure - 1 to 3yrs | Systolic: 95-105, Diastolic:55-70 |
| Blood Pressure Category-Normal | Less than or equal to 120/80 |
| Blood Pressure Category-Elevated | 120-129/less than 80 |
| Blood Pressure Category- High Blood Pressure (Hypertension) stage 1 | 130-139/80-89 |
| Blood Pressure Category-High Blood Pressure (Hypertension) stage 2 | 140-higher/90 or higher |
| Blood Pressure Category-Hypertensive Crisis (Consult your provider immediately) | Higher than 180/higher than 120 |
| Orthostatic Hypotension | (Postural Hypotension) significant drop in blood pressure during positional changes, moving from lying down to sitting or sitting to standing |
| P Wave | Represents ATRIAL DEPOLARIZATION. this is when the atria contracts (upper chamber) |
| ORS Wave Complex | Represents VENTRICULAR DEPOLARIZATION. this is when the ventricles contract (lower chamber) |
| T Wave | Represents VENTRICULAR REPOLARIZATION. this is when the ventricles relax |
| U Wave | Often not seen on an EKG. it represents the repolarization of the ventricles |
| Atria | Two upper chambers of the heart |
| Ventricles | Two lower chambers of the heart |
| Cluster Scheduling | Similar patients grouped for appointments. EX: all immunizations booked on wednesday afternoon each week |
| Open Hours | Patients are seen in the order of arrival during set hours, no scheduled appointments: also known as "first come,first served" or "walk-in clinic" |
| Double-booking | Two patients are assigned the same time slot EX: two patients are scheduled at 9:15am |
| Wave Scheduling | Multiple patients are booked at one time (a "wave" of patients) seen in order of arrival. EX: 5 patients are booked at the beginning of each hour |
| Modified wave scheduling | More patients are scheduled at the beginning of a wave, fewer patients are scheduled towards the end of a wave. EX: 3 patients are booked at the beginning of the hour and 2 patients are booked 30 mins later each hour |
| Stream Scheduling (Time-Specific Scheduling) | Patients are assigned individual appointment times at set intervals EX: Patient A is booked at 9am, patient B is booked at 9:30am, patient C is booked at 10am. |
| SOAP - S | Subjective: Information about the patient's symptoms, as reported by the patient. Ex: Chief complaint(CC), Allergies,History of present illness (HPI), Medications as reported by patient |
| SOAP - O | Objective: Information about the patient's physical examination and diagnostic test results. it is based on objective data, rather than the patient's subjective reports. Ex: Vital Signs, lab results |
| SOAP - A | Assessment: The healthcare provider's interpretation of the patient's condition, based on the subjective and objective information Ex:Diagnosis, summary of patient's health status |
| SOAP - P | Plan: The healthcare provider's proposed actions based on the assessment of the patient Ex: Treatment plan, Follow-up recommendations |
| Lithotomy | Involves the patient lying on their back with their feet supported by stirrups. this position is often used for pelvic exams and Pap smears |
| Semi-Fowler's | A position where the head and upper body are elevated at an angle of 15-45 degree. used for patient's who need to be elevated for comfort or who have some difficulty breathing |
| High Fowler's Position | Bed that is elevated to an angle of 90 degrees (seated upright) used for patients who are having significant trouble breathing (those with chronic obstructive pulmonary disorder (COPD)) |
| Left Lateral - Sims Position | lying on the left side. left hip and left leg are straight, and the right hip and right knee are bent. often used for rectal exams |
| Supine | Patient lying in their back with their arms by their sides. often used for general exams or procedures |
| Preferred Provider Organization (PPO) | Offers more flexibility in choosing healthcare providers, but may come with higher out-of-pocket costs. |
| Health Maintenance Organization (HMO) | Requires a patient choose a primary care physician and receive referrals for specialist care, but generally has lower out-of-pocket costs. |
| Accountable Care Organization (ACO) | A network of healthcare providers that work together to coordinate and provide care to patients with a focus on improving the quality of care and reducing healthcare costs through coordinated and preventive care. (a model not type of insurance) |
| Point of Service (POS) | Health insurance plan similar to HMO, but allows patients to see out-of-network providers for a higher cost. it also requires a primary care physician and referrals to specialists |
| Implied Consent | The assumption of permission to do something that is understood from an individual's actions rather than directly stated. Ex: rolling up their sleeve for a blood draw |
| Explicit Consent | When a patient gives clear and specific permission for a medical treatment Ex: Verbal consent or signing an informed consent document. |
Created by:
Aly99
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