Chapter 2 Medical Terminology Intro to Health Records

A differential diagnosis is

A list of possible causes of the patient's problem or complaint

Alert

able to answer questions; responsive;interactive

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"

Marked

it really stands out

percussion

to hit something and listen to the resulting sound or feel for the resulting vibration

palpation

to feel

diagnosis

what the health care professional thinks the patient has

differential diagnosis

a list of conditions the patient may have based on the symptoms exhibited and the results of the exam

benign

safe

malignant

dangerous; a problem

degeneration

to be getting worse

idiopathic

no known specific cause; it just happens

localized

stays in a certain part of the body

systemic/generalized

all over the body (or most of it)

morbidity

the risk for being sick

occult

hidden

pathogen

the organism that causes the problem

lesion

diseased tissue

sequelae

a problem resulting from a disease or injury

pending

waiting for

disposition

what happened to the patient at the end of the visit

prophylaxis

preventive treatment

palliative

treating the symptoms, but not actually getting rid of the cause

reassurance

to tell the patient the problem is not serious or dangerous

supportive care

to treat the symptoms and make the patient feel better

proximal

closer in to the center

distal

farther away from the center

medial

toward the middle

cranial

toward the top

superior

above

inferior

below

prone

lying down on belly

supine

lying down on back

contralateral

opposite side

unilateral

one side

bilateral

both sides

dorsum

the top of the hand or foot

plantar

the sole of the foot

palmar

the palm of the hand

sagittal

divides the body in slices right to left

coronal

divides the body into slices from front to back

physician

a skilled health care provider who attended and graduated medical school

surgeon

a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure

anesthesiologist

a physician with special training in paid sedation and pain control

physician assistant (PA)

A mid-level health care provider who works under the license of a supervising physician; requires postgraduate training

emergency medical technician (EMT)

Specially trained in the emergency care of a patient before and/or during transport to medical facility

speech therapist

specially trained in evaluating and treating problems with speech and/or swallowing

occupational therapist

specially trained in evaluating and treating problems with performing daily activities at home, school, or work

physical therapist

specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury

respiratory therapist

specially trained in treating patient's respiratory issues under the guidance of a health care provider

dietician

specially trained in evaluating the nutritional status of a patient and developing an appropriate plan

licensed practical nurse(LPN)

licensed vocational nurse

trained and certified to provide basic care to a patient

registered nurse (RN)

An advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education

medical assistant

trained to carry out basic administrative and clinical tasks under the guidance of a health care provider

pathologist

a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine

medical laboratory technician

trained in performing laboratory testing on bodily fluids

ultrasonagrapher

trained in performing ultrasound imaging on a patient

pharmacist

trained and licensed in preparing and dispensing medicine

pharmacy technician

Trained to assist a pharmacist with pharmacy-related tasks

chief complaint

the main reason for the patient's visit

history of present illness

the story of the patient's problem

past medical history

other significant past illnesses, like high blood pressure, asthma, or diabetes

social history

a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

clinical note

documents a visit

consult note

document sent to a primary physician, usually by a specialist, to give an opinion on a more challenging problem

emergency department note

documents a patient's emergency department visit

admission summary

after medical history and a physical exam, it is detailed notes that are very heavy on subjective and objective parts - includes a differential diagnosis (list of possible causes for a patient's problem)

discharge summary

Comprehensive outline of patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans

operative report

Report from surgeon detailing an operation; includes pre- and postoperative diagnosis, specific details of surgical procedure itself, and how patient tolerated procedure

daily hospital note/ progress note

documents a patient's progress during a daily hospital visit

Which health record does not follow the SOAP format?

prescription

Which type of health record is sometimes found in the form of a letter?

consult note

Select the health records that document a type of procedure

operative report

which health care record is NOT routinely used in a hospital or inpatient health care facility?

clinic note

which health record would be used to document a routine pediatric wellness exam?

clinic note

in a problem-based approach, you:

number the problems, describe how the patient's problem has changed, and provide your plan for what to do about the problem

an emergency department course:

explains what transpired during the patient's stay in the emergency department; it includes any diagnostic tests done, the assessment, and a plan for the patient that unfolds over time

identify the author of this type of health record:

operative report

surgeon

identify the author of this type of health record:

radiology report

radiologist

ECU

emergency care unit

ED

emergency department

ICU

intensive care unit

PICU

pediatric intensive care unit

NICU

neonatal intensive care unit

SICU

surgical intensive care unit

PACU

post anesthesia care unit

L&D

labor and delivery

(L)

Left

(B)

bilateral (both sides)

T

temperature

BP

blood pressure

HR

heart rate

RR

respiratory rate

Ht

height

BMI

body mass index

I/O

intake and output

H&P

history and physical

Hx

history

CC

chief complaint

HPI

history of present illness