Chapter 1: The Medical Record Practice Flashcards

These flashcards provide vocabulary and terminology definitions from the Chapter 1 lecture notes on medical records, coding, and clinical documentation styles like SOAP and Operative reports.

Medical Coder

A professional responsible for interpreting medical record documentation into alpha numeric codes.

Evaluation and management (E/M)

Documentation created when a provider evaluates and manages a patient's condition in settings such as an office, hospital, or nursing home.

Operative reports

Reports created when a provider performs a surgery on a patient, detailing components like the procedure, findings, and specimens removed.

Radiology reports

The interpretation of conditions seen on a radiology image, including the indication for the study and a summary of findings.

Laboratory reports

Documentation created when a specimen like blood, skin, or fluids is run through lab equipment and the results are printed.

Palpation

Examination of the body by touch to look for organ size, condition, or tenderness.

Auscultation

The act of listening to body sounds, such as the heart and lungs, often using a stethoscope.

Percussion

Creating sounds by tapping on body areas to examine body organs and cavities using sound vibrations to identify abnormalities.

BP

Abbreviation for Blood pressure.

CC

Abbreviation for Chief complaint, which describes why the patient is presenting for healthcare services.

HEENT

Abbreviation for Head, eyes, ears, nose, throat.

h/o

Abbreviation for History of.

HPI

Abbreviation for History of present illness.

NKDA

Abbreviation for No known drug allergies.

PERRLA

Abbreviation for Pupils equal, round, and reactive to light and accommodation.

PMH

Abbreviation for Past medical history.

ROS

Abbreviation for Review of systems, a series of questions used to gather information and physically assess the patient.

WNL

Abbreviation for Within normal limits.

Subjective (SOAP)

The portion of medical records where the patient provides information about their symptoms.

Objective (SOAP)

The portion of medical records indicating the physical exam findings and vital signs recorded by the provider.

Assessment (SOAP)

The provider's determination or diagnosis regarding the cause of the symptoms.

Plan (SOAP)

The provider's documented strategy to relieve or resolve symptoms, including tests ordered and the provider's thought process.

Time out

A verification process used by healthcare staff to ensure the correct patient and expected procedure before starting surgery.

Preoperative diagnosis

The reason the provider is performing the operation.

Postoperative diagnosis

The diagnosis determined after the operation is complete, which is typically used for coding.

FDP

Flexor Digitorum Profundus; a muscle in the forearm.

DIP joint

Distal interphalangeal joint; the joint at the end of the finger towards the fingernail.

Esmarch

A soft rubber bandage used to expel blood from a limb before surgery.

Takedown

To undo or reverse a previous surgical procedure.

C-Arm

A fluoroscopy machine with an arm shaped like a "C" that circles the surgical table for guidance.

Anteroposterior (AP)

A radiological view taken from front to back.

Decubitus (DEC)

A radiological view taken while the patient is lying on their side.

Oblique (OBL)

An angled radiological view.

Posteroanterior (PA)

A radiological view taken from back to front.

Odontoid

An open mouth cervical spine view used to identify joint space $C1$.

Swimmers

A thoracic X-ray with one or both arms overhead.

Stereo

Two views of a structure taken at different angles.

Apical lordotic

A view of the chest used to include the apex of the lung.

Coronal (Frontal) plane

A plane that divides the body into front and back sections.

Sagittal plane

A plane that divides the body into left and right sides.

Transverse (Horizontal) plane

A plane that divides the body into top and bottom portions.