CH 2: Intro to Health Records- McGraw Hill med language

2.1 Summarize the SOAP method. 2.2 Use common terms on health records. 2.3 Identify the types of health records. 2.4 Use abbreviations associated with heath care facilities, patient care, and prescriptions. 2.5 Become familiar with different types of health record

What type of information do health records contain?

• Previous illnesses and treatments

• Continuing medical problems

• History of family illnesses

• Current medications

What is a SOAP note?

An acronym for the 4 different types of information documented by health care providers in a medical note.

S= Subjective: what the patient says

O= Objective: what the tests reveal

A=Assessment: the analysis of the subjective and objective information; performed by the health care provider.

P=Plan: Course of action for the patient

General subjective terms

• Acute (of short duration but typically severe.)

• Chronic (persisting for a long time or constantly recurring.)

• Abrupt

• Febrile (having or showing the symptoms of a fever)

• Afebrile

• Malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify.)

• Progressive

• Exacerbation (an acute increase in the severity of a problem, illness, or bad situation.)

• Symptom

• Noncontributory (making no contribution to a medical diagnosis; not related to this specific problem)

• Lethargic (a decrease in the level of consciousness; usually an indication that patient is v sick)

• Genetic/Hereditary

General objective Terms: Seen

• Alert

• Oriented

General objective terms: Heard

• Auscultation (n.the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis.)

• Percussion

General objective terms: Felt

Palpitation

General objective terms: Observed

• Unremarkable

• Marked

General assessment terms 1

• Impression

• Diagnosis

• Differential diagnosis

• Benign

• Malignant

• Degeneration (deterioration and loss of function in the cells of a tissue or organ.)

• Etiology (n.the cause, set of causes, or manner of causation of a disease or condition.)

• Idiopathic (cause is unknown; "alone in suffering)

• Remission (temporary recovery)

• Recurrent

General assessment terms 2

• Morbidity (the condition of being diseased.; rate of disease)

• Mortality

• Prognosis (a forecast of the likely course of a disease or ailment.)

• Localized

• Systemic/generalized

• Occult (not manifest or detectable by clinical methods alone)

• Pathogen

• Lesion (a region in an organ or tissue which has suffered damage through injury or disease, such as a wound, ulcer, abscess, or tumor.)

• Sequelae (pathological condition resulting from a disease, injury, therapy, or other trauma)

• Pending

General plan terms

• Disposition (a tendency, either physical or mental, toward a given disease. ; Follow-up list detailed in the health care record, after the initial episode of care, of services and treatments to be provided to the patient.)

• Discharge ( To formally terminate a person's care in and release them from a hospital or healthcare facility.0

• Prophylaxis (Prevention of disease or of a process that can lead to disease.)

• Palliative (giving relief but not curing.)

• Observation

• Reassurance

• Supportive care

• Sterile

Anatomic position

The position of reference in which the patient stands facing you, arms at the side, with the palms of the hands forward.

proximal

Closer to the origin of the body part or the point of attachment of a limb to the body trunk

distal

farther from the origin of a body part or the point of attachment of a limb to the body trunk; farther away from the center

lateral

Away from the midline of the body; out to the side

medial

toward the midline

ventral/antral/anterior

the front (ventral means stomach)

dorsal/posterior

Toward or at the back of the body; behind

cranial

toward the head

caudal (KOW-dal)

toward the bottom ; from Latin, for tail

superior

Above; at a higher level

inferior

below

prone

(adj.) lying face down; lying down on belly

supine

lying down on back

contralateral

on the opposite side of the body

ipsilateral

same side

unilateral

one-sided

bilateral

both sides

dorsum

the top of the hand or foot

plantar

the sole of the foot

palmar

palm of hand

sagittal

• divides the body in slices right to left

• sagitta--> latin for arrow; think of arrow dividing body in half

coronal

• divides the body into slices from front to back

• Corona is Latin for crown; this plane divides body in half from the top of the head down

transverse

divides the body from top to bottom

physician

• a skilled health care provider who attended and graduated medical school

• two types in America:

  1. medical doctor (MD)

  2. doctor of osteopathy (DO)

pediatrician

physician specializing in the treatment of babies and children

surgeon

a physician who specializes in surgery

anesthegiologist

a physician with special training in pain sedation and pain control

physician assistant (PA)

• a midlevel health care provider who works under the license of a supervising physician

• requires postgraduate training

Nurse Practitioner (NP)

• a nurse with postgraduate training who serves as a midlevel health care provider

• works under the license of a supervising physician

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 (PT)

provides treatment to prevent disability or restore function through the use of exercise, heat, massage, or other techniques

respiratory therapist

a specially trained technician who administers, among other treatments, inhalation therapy to patients with lung disease/respiratory issues

dietician

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

licensed practical nurse (LPN)

• A nurse who has completed a 1-year nursing program and has passed a licensing test

• called licensed vocational nurse (LVN) in some states

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 lab medicine

Medical Laboratory Technician

trained in performing laboratory testing on bodily fluids

phlebotomist

trained in removal of blood from the body for diagnostic or therapeutic purposes

radiologist

physician specially trained in evaluating images of the body to diagnose illness or injury

radiology technician

trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider

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

patient service coordinator

handles administrative tasks and coordinates patient care

Medical Transcriptionist

trained in converting the voice-recorded dictations of health care providers into text format

What are the sections of a health care record?

• chief complaint

• History of present illness

• Review of systems

• Past medical history

• Past surgical history

• Family History

• Social History

chief complaint

the main reason for the patient's visit

History of present illness

the story of the patient's problem

Review of systems

description of individual body systems in order to discover any symptoms not directly related to the main problem

past medical history

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

family history

any significant illnesses that run in the patient's family

social history

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

Example report

Subjective: Blue
Objective: Red
Assessment: yellow
Plan: green

Clinic Note

author: medical professional
location: clinic
purpose: documents a visit
format & order: SOAP
unique features: new patient-includes more history, separate form; repeat patient- streamlined note

Consult Note

author: physician; usually a specialist
location: clinic or hospital
purpose: provides an expert opinion on a more challenging problem
format & order: SOAP
unique features: can be in the form of a letter to the PCP

Emergency Department Note

author: ED medical staff
location: emergency department
purpose: documents an emergency department visit
format & order: SOAP
unique features: the A includes the emergency department course

Admission Summary

Author: Hospital medical professional
Location: Hospital
Purpose: Documents the admission of a patient to the hospital
Format & order: SO A/P
Unique features:
S, O = Very thorough
A = Differential diagnosis
P = Further testing and care
A + P = Problem-based approach

Discharge Summary

author: Medical professional
Location: Hospital
Purpose: Describes when and why the patient was admitted; documents a longer stay
Format & Order: ASOP
Unique Feature: Starts with A

Operative Report

author: surgeon
location:
Purpose: documents a surgery in detail
format & order: ASOP
unique features:

Radiology Report

• Radiologist

• Explains reason for image, how image was performed, what was seen on image, radiologist's assessment; sometimes a recommendation

• SOA

• Usually includes only S, O, and A, but may include a P if it recommends that further studies should be performed

Pathology Report

Author: Pathologist
Location:
Purpose: Provides reasons for test, what was seen on the test, and an assessment
Format & order: SOA
Unique features:

Prescription

Author: medical professional
Purpose: Provides directions for a medication
Format: P

Unique features:

1. Medicine's name

2. Instructions for patient

3. How much medicine should be given

4. Refills, if any

5. Health care professional's signature and whether generic substitution is allowed

CCU

coronary care unit

ECU

emergency care unit

ER

emergency room

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 & delivery

OR

operating room

post-op

after surgery

pre-op

before surgery

male symbol

♂

female symbol

♀

Right, Left, Bilateral

(R), (L), (B)

VS

vital signs

T

temperature

BP

blood pressure

HR

heart rate

RR

respiratory rate

Ht

height

Wt

weight

BMI

body mass index

I/O

intake and output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)