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Word Parts/Terms/Abb

Med Terminology, Chapter 2 SOAP, records and abbreviations

TermDefinition
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)
Created by: Tmarter
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