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Chapter 2
| Question | Answer |
|---|---|
| What does SOAP stand for | S = subjective O = objective A = assessment P = plan |
| What does the S include; what color | patient experiences and patient describes the problem also includes personal and family medical histories blue |
| What does the O include; what color | physical exam, lab findings, and imaging studies preformed at the visit red |
| What does the A include; what color | diagnosis, identification of problem, or differential diagnosis yellow |
| What does the P include; what color | treatment or a procedure could also include conducting further data to get a more accurate diagnosis green |
| Acute | just started recently or is a sharp severe symptom |
| chronic | going on for awhile |
| exacerbation | it is getting worse |
| abrupt | all of a sudden |
| febrile | has a fever |
| afebrile | no fever |
| malaise | not feeling well |
| progressive | more and more each day |
| symptom | something the patient feels |
| noncontributory | not related to the specific problem |
| lethargic | a decrease in the level of consciousness; really sick |
| genetic/hereditary | runs in the family |
| alert | responsive and interactive |
| oriented | aware of surroundings and who they are and the time |
| marked | abnormal |
| unremarkable | normal |
| auscultation | to listen |
| precussion | vibration |
| palpation | to feel |
| impression | assessment |
| diagnosis | what the patient might have |
| differential diagnosis | list of conditions the patient might have based on symptoms |
| benign | safe |
| malignant | dangerous |
| degeneration | getting worse |
| remission | getting better or improving |
| idiopathic | no known specific cause |
| localized | stays in certain part of body |
| systemic/generalized | all over the body |
| prognosis | chances of getting better or worse |
| occult | hidden |
| lesion | diseased tissue |
| recurrent | to have again |
| sequela | a problem resulting from a disease or injury |
| pathogen | organism that causes the problem |
| morbidity | the risk for being sick |
| mortality | the risk for dying |
| etiology | the cause |
| disposition | what happened at the end of the visit |
| discharge | to send home or fluid coming out |
| palliative | treating the symptoms but not getting rid of the cause |
| observation | watch |
| sterile | very clean |
| prophylaxis | preventative treatment |
| cheif complant | reason for visit |
| history of present illness | story of problem |
| review of systems | descriptions of body systems in order to discover problems not related to illness |
| past medical history | other illnesses |
| past surgical history | past surgeries |
| family history | significant illnesses that run in the family |
| social history | habits like smoking and drinking |
| what is a clinical note | anytime a health care professional sees a patient in an oficce setting |
| consult note | specialist to PCP |
| ED note | in urgent care or ED, special section which explains what happens during their stay at the ED like any tests or assessments |
| Admission Summary | heavy on the subjective and objective parts; sent to the PCP; right after admittance into the hospital |
| discharge summary | details on when and why the patient were admitted; leads with the diagnosis |
| operative report | what happens during a surgery and patients' outcome; diagnosis is at the beginning |
| progress note/daily note | subjective part focuses on how the condition has changed; A+P together |
| Radiology/Pathology report | reason for study/imaging and what was seen in detail |
| Prescription | it is the plan 1. name and strength 2. sig/instructions 3. dispense/amount 4. refills available |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care unit |
| PACU | post-anesthesia care unit |
| L&D | labor and delivery |
| OR | operating room |
| post-op | after surgery |
| pre-op | before surgery |
| I/O | intake/output |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint |
| HPI | history of present illness |
| ROS | review of systems |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| h/o | history of |
| f/u | follow up |
| SOB | shortness of breath |
| HEENT | head, eyes, ears, nose, and throat |
| PERRLA | pupils are equal, round, reactive to light and accommodation |
| NAD | no acute distress |
| CV | cardiovascular |
| RRR | regular rate and rhythm |
| CTA | clear to auscultation |
| WDWN | well developed, well nourished |
| A&O | alert and oriented |
| WNL | within normal limits |
| NOS | not otherwise specified |
| NEC | not elsewhere classified |
| PO | by mouth |
| NPO | nothing by mouth |
| PR | anal/per rectum |
| IM | intramuscular |
| SC | subcutaneous |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | instructions |
| BID | twice daily |
| TID | three times daily |
| Q | every x number of times |
| QD | daily |
| QID | four times daily |
| QHS | at night |
| AC | before meals |
| PC | after meals |
| prn | as needed |
| ab lib | as desired |
Created by:
abakemeye
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