STUDY CHAP 2. - MED TERM

intro to med

subjective

info on patient's personal experience

objective

info through physical examination

assessment

diagnosis

plan

course of action from assessment

chief complaint

main reason for the patient's visit

exacerbation

worsening of a condition

malaise

feeling unwell/bad

unremarkable

normal; no abnormal findings

sequela

condition remaining from previous disease/injury

prophylaxis

preventive treatment

idiopathic

no specific cause

health record

record of a patient's medical care and history

clinic note

record of a patient's visit in a clinical setting

consult note

record from another healthcare professional to evaluate a patient

emergency department note

record of a patient’s visit to the emergency department.

daily hospital note

documentation of a patient's daily progress in a hospital

progress note

documentation describing changes in a patient's condition and ongoing care

admission summary

summary documenting a patient's admission to a healthcare facility

discharge summary

summary of a patient's hospitalization and discharge

operative report

report of a surgery procedure

radiology report

report describing findings from medical imaging

pathology report

report describing findings from tissue/specimen examinations

prescription

written instructions for using a medication

medical history

information about a patient's previous health conditions and medical care

chief concern

main problem or reason the patient is seeking care

symptom

something experienced or reported by the patient

sign

something observed or measured by a healthcare professional

diagnosis

identification of a disease or condition

differential diagnosis (different reasons)

list of possible diagnoses being considered

vital signs

measurements of the body’s basic life functions.

physical examination

examination of the patient's body by a healthcare professional

laboratory findings

results obtained from laboratory testing

imaging studies

tests that produce images of structures inside the body

anesthesiologist

physician specializing in anesthesia and pain control

pathologist

physician specializing in disease and laboratory medicine

ultrasonographer

healthcare professional trained to perform ultrasound imaging

pharmacist

healthcare professional trained and licensed to prepare and dispense medications

emergency medical technician (EMT)

professional trained to provide emergency care before and/or during transportation to a medical facility

medical transcriptionist

professional who converts recorded healthcare-provider dictation into written text

Pt

patient

PMHx

past medical history

BMI

body mass index

CC

chief complaint

EMT

emergency medical technician