Chapter 2
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| What does each letter in SOAP stand for? | S- subjective
O- objective
A- Assessment
P- Plan
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| What is the subjective part of a medical note? | how the patient experiences and personally describes the problem as well as personal and family medical histories.
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| What is the objective part of a medical note? | the investigative process of collecting objective data such as patient's physical exam, any laboratory findings and imaging studies performed at the visit.
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| What is the assessment part of a medical note? | upon gathering all the pertinent information, the health care provider formulates a logical analysis. An assessment could be a diagnosis, and identification of a problem, or a list of possibilities for the diagnosis (differential diagnosis)
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| What is the plan part of a medical note? | a course of action consistent with the assessment such as treatment with medicine or a procedure. It could also consist of collecting further data to help a more accurate diagnosis.
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| what is the definition of acute? | it just started recently or is a sharp, severe syptom
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| what is the definition of chronic? | it has been going on for a while now
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| what is the definition of exacerbation? | it is getting worse
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| what is the definition of abrupt? | all of a sudden
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| what is the definition of febrile? | to have a fever
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| what is the definition of afebrile? | to not have a fever
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| what is the definition of malaise? | not feeling well
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| what is the definition of progressive? | more and more each day
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| what is the definition of symptom? | something a patient feels
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| what is the definition of noncontributory? | not related to this specific problem
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| what is the definition of lethargic? | a decrease level of consciousness; in a medical record, this is generally an indication that the patient is really sick
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| what is the definition of genetic/hereditary? | it runs in the family
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| what is the definition of alert? | able to answer questions; responsive; interactive
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| what is the definition of oriented? | being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is oriented x 3
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| what is the definition of marked? | it really stands out
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| what is the definition of unremarkable? | another way of saying normal
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| what is the definition of auscultation? | to listen
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| what is the definition of percussion? | to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument
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| what is the definition of palpation? | to feel
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| what is the definition of impression? | another way of saying assessment
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| what is the definition of diagnosis? | what the health care professional thinks the patient has
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| what is the definition of differential diagnosis? | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam
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| what is the definition of benign? | safe
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| what is the definition of malignant? | dangerous; a problem
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| what is the definition of degeneration? | to be getting worse
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| what is the definition of remission? | to get better or improve; most often used when discussing cancer; remission does not mean cure
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| what is the definition of idiopathic? | no known specific cause; it just happens
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| what is the definition of localized? | stays in a certain part of the body
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| what is the definition of systemic/generalized? | all over the body (or most of it)
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| what is the definition of prognosis? | the chances for things getting better or worse
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| what is the definition of occult? | hidden
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| what is the definition of lesion? | diseased tissue
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| what is the definition of recurrent? | to have again
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| what is the definition of sequeia? | a problem resulting from a disease or injury
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| what is the definition of pending? | waiting for
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| what is the definition of pathogen? | the organism that causes the problem
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| what is the definition of morbidity? | the risk for being sick
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| what is the definition of mortality? | the risk for dying
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| what is the definition of etiology? | the cause
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| what is the definition of disposition? | what happened to the patient at the end of the visit
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| what is the definition of discahrge? | to unload
1. to send home
2. fluid coming out of a part of the body
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| what is the definition of pallative? | treating the symptoms, but not actually getting rid of the cause
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| what is the definition of observation? | watch, keep an eye on
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| what is the definition of reassurance? | to tell the patient that the problem is not serious or dangerous
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| what is the definition of supportive care? | to treat the symptoms and make the patient feel better
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| what is the definition of sterile? | extremely clean, germ-free conditions; especially important during medical procedures and surgery
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| what is the definition of prophylaxis? | preventative treatment
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| What does PO stand for? | per os (by mouth)
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| What does NPO stand for? | nil per os (nothing by mouth)
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| What does PR stand for? | per rectum (anal)
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| What does IM stand for? | intramuscular
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| What does SC stand for? | subcutaneous (under the skin)
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| What does IV stand for? | intravenous
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| What does CVL stand for? | central venous line
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| What does PICC stand for? | peripherally inserted central catheter
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| What does Sig stand for? | instructions short for signa, from Latin, for "label"
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| What does BID stand for? | twice daily
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| What does TID stand for? | three times daily
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| What does Q stand for? | every x (EX: Q4hr would mean every 4 hours or Q3 would be every 3 days)
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| What does QD* stand for? | daily
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| What does QID* stand for? | four times daily
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| What does QHS stand for? | at night
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| What does AC stand for? | before meals
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| What does PC stand for? | after meals
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| What does prn stand for? | as needed
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| What does ad lib stand for? | as desired
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