medical terms 2
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| EHR | Electronic Health Record
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| roadmap | The information contained in a patient's records serves as a __________ to their health history detailing previous illnesses and treatments, continuing medical problems, history of family illness, and any current meds.
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| Subjective, Objective, Assessment, Plan (SOAP) | the four general parts of a medical note
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| Subjective | the patient's personal story of health issue: reason for visit, description of problem, timing, previous problems/surgeries, family health issues, current meds/allergies
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| acute | started recently or sharp and severe symptom
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| chronic | has been going on for a while
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| exacerbation | it is getting worse
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| abrupt | all of a sudden
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| febrile | to have a fever
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| afebrile | to not have a fever
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| malaise | not feeling well
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| progressive | more and more each day
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| symptom | something a patient feels
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| noncontributory | not related to this specific problem
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| lethargic | a decrease in level of consciousness, usually means really sick in medical records
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| genetic/hereditary | runs in the family
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| chief complaint | the main reason for a patient's visit
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| history of present illness | the story of the patient's problem
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| review of symptoms | description of individual body symptoms in order to discover any symptoms not directly related to the main problem
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| past medical history | other significant past illnesses, like high blood pressure, asthma, or diabetes
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| past surgical history | any of the patient's past surgeries
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| family history | any significant illnesses that run in the patient's family
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| social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
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| clinic note | document of a visit in an office setting. always follows the SOAP method
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| consult note | a note from a visit to a specialist or consultant
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| emergency department note | a note given to emergency departments in need of information on a patient
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| admission summary | a summary of a patient's physical details upon being admitted to a hospital
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| discharge summary | a note that details when and why a patient was admitted to the hospital, what happened, how the patient felt, and a follow-up plan.
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| operative report | a report after each surgery explaining the procedure, the events that transpired, and patient's outcome
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| daily hospital note/progress note | a document made every day a patient is in a hospital, usually covers how their condition has changed since the day before.
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| radiology report | a note explaining the reason for ordering a radiologic image, how image was performed, and what was seen on the image, and the reviewing radiologist's assessment
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| pathology report | mirrors the same style as a radiology note, but for pathology
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| prescription | a note that doesn't follow SOAP format, it's the plan.
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| CCU | coronary care unit
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| ECU | emergency care unit
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| ER | emergency room
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| ED | emergency department
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| ICU | intensive care unit
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| PICU | pediatric intensive care unit
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| NICU | neonatal intensive care unit
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| SICU | surgical intensive care unit
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| PACU | post-anesthesia care unit
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| L&D | labor and delivery
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| OR | operating room
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| post-op | after surgery
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| pre-op | before surgery
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| alert | able to answer questions, responsive
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| oriented | being aware of who they are, where they are, and the current time
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| marked | it stands out
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| unremarkable | normal
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| auscultation | to listen
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| percussion | to hit something and listen to the resulting sound or feel for resulting vibration
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| palpation | to feel
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| impression | assessment
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| diagnosis | what the health care professional thinks the patient has
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| differential diagnosis | list of conditions patient may have based on the symptoms exhibited and the results of the exam
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| benign | safe
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| malignant | dangerous, a problem
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| degeneration | to be getting worse
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| remission | to get better or improve, most often used when discussing cancer
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| idiopathic | no known specific cause, just happens
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| localized | stays in a certain part of the body
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| systemic/generalized | all over the body or most of the body
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| prognosis | the chances for things getting better or worse
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| occult | hidden
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| lesion | diseased tissue
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| recurrent | to have again
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| sequela | a problem resulting from a disease or injury
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| pending | waiting for
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| disposition | what happened to the patient at the end of the visit, used at end of ED notes to reference where patient went after visit
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| discharge | to send home, or fluid coming out of part of body
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| palliative | treating the symptoms but not the cure
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| observation | watch, keep an eye on
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| reassurance | tell the patient that the problem is not serious or dangerous
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| supportive care | to treat the symptoms and make the patient feel better
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| sterile | extremely clean, germ free conditions
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| proximal | closer to the center
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| distal | farther from center
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| lateral | out to the side
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| medial | toward the middle
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| ventral | the front
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| dorsal | the back
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| cranial | towards top
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| caudal | towards bottom
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| superior | above
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| inferior | below
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| prone | lying down on belly
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| supine | lying down on back
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| contralateral | opposite side
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| ipsilateral | same side
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| unilateral | one side
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| bilateral | both sides
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| dorsum | the top of hand or foot
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| plantar | sole of foot
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| palmar | palm of hand
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| saggital | divides body from left and right
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| coronal | divides body front and back
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| transverse | divides body top to bottom
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| physician | skilled healthcare provider who attended and graduated medical school
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| pediatrician | physician with special training for children
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| surgeon | physician qualified to treat patients surgically by means of operation or invasive procedure
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| anesthesiologist | physician with special training on pain sedation and pain control
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| epidemiologist | specialist in study of causes and distribution of diseases in populations and the use of this data will enhance public health
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| physician assistant (PA) | midlevel healthcare provider who works under the license of a supervising physician, requires postgraduate training
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| nurse practitioner (NP) | nurse with postgraduate training that serves as midlevel healthcare provider, works under supervising physician
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| emergency medical technician | specially trained in evaluating and treating problems with speech and/or swallowing
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| occupational therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from injury
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| respiratory therapist | trained in treating patients respiratory issues under guidance of a healthcare provider
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| dietician | trained in evaluating the nutritional status of a patient and developing diet plan
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| licensed practical nurse (LPN) | trained and certified to provide basic care to a patient
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| registered nurse (RN) | advanced level nurse who has completed an associate's or bachelor's degree, assists with patient care planning and patient education
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| medical assistant | trained to carry out basic administrative and clinical tasks under guidance of a healthcare provider
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| pathologist | physician with special training in both evaluating the causes and effects of disease and in laboratory medicine
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| medical laboratory technician | trained in performing laboratory testing on bodily fluids
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| phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes
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| radiologist | physician trained in evaluating images of the body to diagnose illness or injury
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| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a healthcare provider
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| ultrasonographer | trained in performing ultrasound imaging on a patient
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| pharmacist | trained and licensed in preparing and dispensing medicine
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| pharmacy technician | trained to assist a pharmacist with pharmacy related tasks
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| patient service coordinator | handles administrative tasks and coordinates patient care
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| medical transcriptionist | trained in converting voice recorded dictations of healthcare providers into text format
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| VS | vital signs
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| T | temperature
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| BP | blood pressure
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| HR | heart rate
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| RR | respiratory rate
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| Ht | height
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| Wt | weight
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| BMI | body mass index
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| I/O | intake/output
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| Dx | diagnosis
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| DDx | differential diagnosis
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| Tx | treatment
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| Rx | prescription
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| H&P | history and physical
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| Hx | history
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| CC | chief complaint
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| HPI | history of present illness
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| ROS | review of systems
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| PMHx | past medical history
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| FHx | family history
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| NKDA | no known drug allergies
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| PE | physical exam
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| Pt | patient
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| y/o | years old
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| h/o | history of
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| PCP | primary care provider
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| f/u | follow up
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| SOB | shortness of breath
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| HEENT | head, eyes, ears, nose, and throat
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| PERRLA | pupils are equal, round, reactive to light and accomadations
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| NAD | no acute distress
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| CV | cardiovascular
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| RRR | regular rate and rhythm
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| CTA | clear to auscultation
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| WDWN | well developed well nourished
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| A&O | alert and oriented
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| WNL | within normal limits
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| NOS | not otherwise specified
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| NEC | not elsewhere classified
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| PO | per os (by mouth)
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| NPO | nil per os (nothing by mouth)
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| PR | per rectum
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| IM | intramuscular
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| SC | subcutaneous
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| IV | intravenous
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| CVL | central venous line
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| PICC | peripherally inserted central catheter
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| Sig | instructions
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| BID | twice daily
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| TID | three times daily
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| Q | every x (every x hours)
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| QD | daily
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| QID | four times daily
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| QHS | at night
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| AC | before meals
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| PC | after meals
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| prn | as needed
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| ad lib | as desired
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