Medical Language
Help!
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| " SOAP Method " | S - Subjective: what patient says.
O - Objective: What the test reveal.
A - Assessment: Analysis of the Subjective and Objective information.
P - Plan: The course of action for the patient.
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| Subjective Terms | Acute vs. Chronic Progressive vs. exacerbation
Abrupt Symptom
Febrile vs. Afebrile Noncontributory
Malaise
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| Objective Terms | Things that are seen:
Alert
Oriented
Things that are heard:
Auscultation
Percussion
Things that are felt:
Palpation
Descriptions of what is observed:
Unremarkable
Marked
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| Assessment Terms | Impression
Diagnosis
Differential diagnosis
Benign vs. malignant
Degeneration
Etiology vs. idiopathic
Remission
Recurrent
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| Plan Terms | Impression
Diagnosis
Differential diagnosis
Benign vs. malignant
Degeneration
Etiology vs. idiopathic
Remission
Recurrent
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| Anatomical position | a person standing face forward, arms at the side with palms forward.
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| Common on Health Records | VS (vital signs) are made up of the HR (heart rate)
RR (respiratory rate), BP (blood pressure), and T (temperature)
Ht – height
Wt – weight
BMI – body mass index
I/O – input/output
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| Common on Health Records | Dx – diagnosis
DDx – differential diagnosis
Tx – treatment
Rx – prescription
Hx (history)
PMHx (past medical history); FHx (family history)
H&P – history and physical
CC – chief complaint
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| Areas of the Health Care Facility | Pre-op: This area prepares the patient for surgery.
OR: operation room.
PACU: Post anesthesia care unit.
Post-op: Post operative room.
ICU: intensive care unit
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| Health professionals | Pharmacist Ultrasonographer
Pharmacy technician Register Nurse
Patient service coordinator
Medical transcriptionist
Pathologist
Medical laboratory technician
Phlebotomist
Radiologist
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| Body Planes and Orientation | Proximal Coronal Ipsalateral
Lateral Sagital Craneal
Distal Dorsal
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Created by:
Nicolle 26
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