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MA Notes

TermDefinition
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)
Created by: Aly99
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