| Term | Definition |
| SOAP Method | S = Subjective: what the patient says
O = Objective: what the tests reveal
A = Assessment: the analysis of the subjective
and objective information; performed by
the health care provider
P = Plan: the course of action for the patient |
| Abrupt | sudden and unexpected |
| Malaise | a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify |
| Symptom | a physical or mental feature which is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient |
| Noncontributory | not playing a part in bringing something about. |
| Lethargic | Close to death |
| Impression | The impression may include a short sentence with a diagnosis. Other times the impression may include multiple sentences or impression points. There may be more then one diagnosis. There may be an explanation of the findings. |
| Diagnosis | the identification of the nature of an illness or other problem by examination of the symptoms |
| Differential diagnosis | the process of differentiating between two or more conditions which share similar signs or symptoms. |
| Benign vs. malignant | The tumor doesn’t contain cancerous cells. and The tumor contains cancerous cells |
| Degeneration | the state or process of being or becoming degenerate; decline or deterioration |
| Etiology vs. idiopathic | An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin.[ |
| Remission | Abatement or lessening in severity of the symptoms of a disease. |
| Recurrent | occurring often or repeatedly |
| Morbidity | the condition of suffering from a disease or medical condition |
| Mortality | the state of being subject to death |
| Prognosis | the likely course of a disease or ailment |
| Localized vs. systemic/generalized | A systemic illness is one that affects the entire body, rather than a single organ or body part. Many organs and tissues might be involved in the complex disease process. |
| Occult | to refer to pathology that cannot be seen on more or more modalities. |
| Pathogen | a bacterium, virus, or other microorganism that can cause disease. |
| Lesion | a region in an organ or tissue which has suffered damage through injury or disease, such as a wound, ulcer, abscess, or tumor |
| Sequela | A condition which is the consequence of a previous disease or injury |
| Pending | Info has not been sent to the carrier yet. |
| Disposition | The destination of the patient after hospital discharge |
| Discharge | To tell someone offically, that they can or must leave a place or situation |
| Prophylaxis | Action taken to prevent disease, especially by specified means or against a specified disease |
| Palliative | Relieving symptoms without without dealing with the cause of the condition |
| Observation | The action or process of observing something or someone carefully or in order to gain info |
| Reassurance | Removing someone's doubts our fears |
| Supportive care | Palliative care |
| Sterile | Free of bacteria or other living microorganisms |
| physician
fih-ZISH-un | a skilled health care provider who attended and
graduated medical school
There are two types who practice in America: medical
doctor (MD) and doctor of osteopathy (DO). |
| pediatrician
pee-dee-ah-TRISH-un | a physician with special training in caring for children |
| surgeon
SIR-jen | physician qualified to treat patients surgically, that
is, by means of operation or invasive procedure |
| anesthesiologist
AN-es-THEE-zee-AWL-oh-jist | a physician with special training in pain sedation and
pain control |
| physician assistant (PA)
fih-ZISH-un ah-SIS-tant | a midlevel health care provider who works under the
license of a supervising physician; requires
postgraduate training |
| nurse practitioner (NP)
NIRS prak-TISH-ih-ner | a nurse with postgraduate training that serves as
a midlevel health care provider; works under the
license of a supervising physician |
| emergency medical technician (EMT)
eh-MIR-jen-see MED-ih-kal tek-NISH-
un | specially trained in the emergency care of a
patient before and/or during transport to medical
facility |
| speech therapist
SPEECH THER-ah-pist | specially trained in evaluating and treating
problems with speech and/or swallowing |
| occupational therapist
aw-kyoo-PAY-shuh-nal THER-ah-pist | specially trained in evaluating and treating
problems with performing daily activities at home,
school, or work |
| physical therapist
FIZ-ih-kal THER-ah-pist | specially trained in evaluating and treating
physical impairments including disabilities or
recovery from an injury
23 |
| respiratory therapist
res-PIR-ah-toh-ree THER-ah-pist | specially trained in treating patient’s respiratory
issues under the guidance of a health care provider |
| dietician
dai-ah-TIH-shun | specially trained in evaluating the nutritional status
of a patient and developing an appropriate diet plan |
| licensed practical nurse (LPN)
LAI-senzd PRAK-tih-kal NIRS | trained and certified to provide basic care to a
patient |
| licensed vocational nurse (LVN)
LAI-senzd voh-KAY-shun-al NIRS | A nurse that provides basic patient care. |
| registered nurse (RN)
REH-jis-terd NIRS | an advanced level nurse who has completed an
associate’s or bachelor’s degree; often assists with
patient care planning and patient education |
| medical assistant
MED-ih-kal ah-SIS-tant | trained to carry out basic administrative and clinical
tasks under the guidance of a health care provider |
| pathologist
pah-THAWL-oh-jist | a physician with special training in both evaluating the
causes and effects of disease and in laboratory medicine |
| medical laboratory technician
MED-ih-kal LAB-rah-TOR-ee tek-NISH-un | trained in performing laboratory testing on bodily fluids |
| phlebotomist
fle-BAWT-oh-mist | trained in the removal of blood from the body for diagnostic
or therapeutic purposes |
| radiologist
ray-dee-AWL-oh-just | a physician specially trained in evaluating images of the
body to diagnose illness or injury |
| radiology technician
ray-dee-AWL-oh-jee tek-NISH-un | trained to perform radiologic testing or administer radiation
therapy under the direction of a health care provider |
| ultrasonagrapher
UL-trah-soh-NAWG-rah-fer | trained in performing ultrasound imaging on a patient |
| pharmacist
FAR-mah-sist | trained and licensed in preparing and dispensing
medicine |
| pharmacy technician
FAR-mah-see tek-NISH-un | rained to assist a pharmacist with pharmacy-
related tasks |
| patient service coordinator
PAY-shent SIR-vis coh-OR-dih-nay-tor | handles administrative tasks and coordinates
patient care |
| medical transcriptionist
MED-ih-kal tranz-KRIP-shon-ist | trained in converting the voice-recorded dictations
of health care providers into text format |
| Chief complaint | The main reason for the patient’s visit |
| History of present illness | The story of the patient’s problem |
| Review of systems | Description of individual body systems in
order to discover any symptoms not directly
related to the main problem |
| Past medical history | Other significant past illnesses, like high blood
pressure, asthma, or diabetes |
| Past surgical history | Any of the patient’s past surgeries |
| Family history | Any significant illnesses that run in the
patient’s family |
| Social history | A record of habits like smoking, drinking, drug
abuse, and sexual practices that can impact
health |
| ♂ | male |
| ♀ | Female |
| (R) | Right |
| (L) | Left |
| (B) | bilateral (both sides) |
| ↑ | Increased |
| ↓ | Decreased |
| PERRLA | alert and oriented |
| NOS | regular rate and rhythm |
| RRR | no acute distress |
| CTA | pupils equal, round, and reactive to light and
accommodation |
| A&O | not otherwise specified |
| NAD | clear to auscultation |
| PO | intravenous |
| IV | central venous line |
| SC | per rectum (anal) |
| CVL | per os (by mouth) |
| IM | subcutaneous |
| PR | nil per os (nothing by mouth) |
| NPO | intramuscular |
| prn | three times a day |
| QID | as needed |
| QD | four times a day |
| AC | before meals |
| TID | every day |
| BID | after meals |
| PC | at night |
| QHS | two times a day |
