SOAP Method and General Terms
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| acute | started recently or is a sharp, severe symptom | Subjective
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| chronic | has been going on for a while | Subjective
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| exacerbation | is getting worse | Subjective
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| abrupt | all of a sudden | Subjective
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| febrile | to have a fever | Subjective
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| afebrile | to NOT have a fever | Subjective
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| malaise | not feeling well | Subjective
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| progressive | more and more each day | Subjective
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| symptom | something a patient feels | Subjective
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| noncontributory | not related to this specific problem | Subjective
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| lethargic | a decrease in level of consciousness; in a medical record, this is a general indication that the patient is really sick | Subjective
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| genetic/hereditary | it runs in the family | Subjective
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| alert | able to answer questions; responsive; interactive | Objective
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| oriented | being aware of who they are, where they are, and the current time; patient aware of all three is "oriented times 3" | Objective
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| marked | it really stands out | Objective
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| unremarkable | another way of saying normal | Objective
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| auscultation | to listen | Objective
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| percussion | to hit something and listen to the resulting sound or feel for the resulting vibration | Objective
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| palpation | to feel | Objective
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| impression | another way of saying assessment | Assessment
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| diagnosis | what health care professional thinks the patient has | Assessment
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| differential diagnosis | a list of condition the patient may have based on the symptoms exhibited and the results of the exam | Assessment
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| benign | safe | Assessment
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| malignant | dangerous; a problem | Assessment
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| degeneration | to be getting worse | Assessment
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| remission | to get better or improve; does not mean cure; mostly from discussing cancer | Assessment
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| idiopathic | no known specific cause; it just happens | Assessment
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| localized | stays in a certain area of the body | Assessment
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| systemic/generalized | all over the body ( or most of it) | Assessment
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| prognosis | the chances for things getting better or worse | Assessment
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| occult | hidden | Assessment
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| lesion | diseased tissue | Assessment
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| recurrent | to have again | Assessment
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| sequela | a problem resulting from a disease or injury | Assessment
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| pending | waiting for | Assessment
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| pathogen | organism that causes the problem | Public Health
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| morbidity | the risk for being sick | Public Health
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| mortality | the risk for dying | Public Health
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| etiology | the cause | Public Health
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| disposition | what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit(home, ICU, normal hospital bed) | Plan
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| discharge | literally, to unload; it has two meanings: 1. to send home (unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (body unloading a fluid) | Plan
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| palliative | treating the symptoms, but not actually getting rid of the cause | Plan
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| observation | watch, keep an eye on | Plan
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| reassurance | to tell the patient that the problem is not serious or dangerous | Plan
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| supportive care | to treat the symptoms and make the patient feel better | Plan
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| sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery` | Plan
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| prophylaxis | preventive treatment | Public Health
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