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Word Parts/Terms/Abb
Med Terminology, Chapter 2 SOAP, records and abbreviations
| Term | Definition |
|---|---|
| IPSILATERAL | IP-sih-LAT-eh-ral Definition: SAME SIDE |
| LESION | LEE-zhun Definition: DISEASED TISSUE or INJURY |
| UNILATERAL | YOO-nih-LAT-er-al Definition: ONE SIDE |
| TRANSVERSE | trans-VERSE Definition: Imaginary Horizontal line, Dividing the body into UPPER and LOWER sections. |
| ORIENTED | Definition: Patient is able to identify one's name, location, time/date. X3 = NAME+LOCATION+DAY/DATE |
| OBJECTIVE | "O" in the SOAP model of medical documentation Examples: Patient's Physical Exam, Laboratory Findings, Imaging Studies |
| MORBIDITY | The Risk of ILLNESS (sickness) |
| MORTALITY | The Risk of DEATH (dying) |
| SAGITTAL PLANE | An imaginary Verticle line that runs from the top to the bottom of the body, Dividing it into RIGHT AND LEFT sections. |
| CORONAL PLANE | An imaginary VERTICAL line that runs from the top to the bottom of the body, DIVIDING it into FRONT and BACK sections. |
| DDx | DIFFERENTIAL DIAGNOSIS Definition: A list of possibilities within the ASSESMENT of the SOAP medical documentation model. |
| CTA | Clear To Auscultation Example: description of normal sounding lungs |
| Q | Q = EVERY Example: Q4hrs = EVERY 4 hours Q2days = EVERY 2 days |
| (B) | BILATERAL (both sides) |