Medical Terminology - EXAM1

CH1-CH3

SOAP Method

Subjective, Objective, Assessment, Plan

SOAP Method - Subjective

How a patient describes or experiences the problem. Family & personal medical history.

SOAP Method - Objective

Physical exams, lab findings, imaging studies, etc.

SOAP Method - Assessment

List of possible diagnoses (Differential diagnosis), diagnosis, or identification of the problem

SOAP Method - Plan

Course of action, treatment, procedure, collection of further data, etc.

SOAP Method - Blue color coding

Subjective

SOAP Method - Red color coding

Objective

SOAP Method - Yellow color coding

Assessment

SOAP Method - Green color coding

Plan

SOAP Method - Light Green color coding

Assessment & Plan

Chief Complaint

Main reason for pt’s visit

History of Present Illness

The story of pt’s problem

Review of Systems

Description of individual body systems to discover symptoms not directly related to main problem

Past Medical History

Other significant past illnesses (asthma, high blood pressure, etc.)

Past Surgical History

Pt’s past surgeries

Family History

Significant illnesses that run in the family

Social History

Record of habits that can impact health (alcohol, tobacco, drugs, etc.)

How is a Prescription written?

Doesn’t follow the SOAP Method as it is the Plan.

1. Name/Strength of medicine

2. Marked “Sig” - pt’s instructions

3. Marked “Dispense” - How much of medicine to provide

4. Refills available

5. Health care provider’s signature

Unique Features of a Clinic Note

Written by a Medical Professional at a Clinic. Documents a visit.

Unique Features of a Consult Note

Written by a Physician (Specialist) at a Clinic or Hospital. Can be in the form of a letter to PCP.

Unique Features of an Emergency Department Note

Written by ED medical staff at an ED. The Assessment includes ED course.

Unique Features of an Admission Summary

Written by a Hospital medical professional at a Hospital. Very thorough S/O, A includes differential diagnosis, A & P includes problem-based approach.

Unique Features of a Discharge Summary

Written by a medical profession in a Hospital. Starts with Assessment (ASOP)

Unique Features of an Operative Report

Written by a Surgeon. Starts with Assessment (ASOP)

Unique Features of a Daily Hospital/Progress Report

Written by a Medical Professional in an Inpatient Healthcare Facility. Subjective focuses on how pt’s condition has changed since previous note.

Unique Features of a Radiology Report

Written by a Radiologist. Generally only SOA - P is only included if further studies need to be performed.

Unique Features of a Pathology Report

Written by a Pathologist. Generally only SOA - P is only included if further studies need to be performed.

Unique Features of a Prescription

Written by a Medical Professional. This is only a Plan - no SOA.

Acute

Just started recently or a sharp/severe symptom

Chronic

ongoing for awhile

Exacerbation

Worsening

Abrupt

Suddenly

Febrile

Fever

Afebrile

No fever

Malaise

Feeling unwell

Progressive

More each day

Symptom

What a pt feels

Noncontributory

Not related to specific problem

Lethargic

Decrease in level of consciousness - generally an indication the pt is very sick

Genetic/Hereditary

Runs in the family

Alert

Able to answer questions, responsive, or interactive

Oriented

Aware of who they are, where they are, and when they are - Pt who is all three is Alert & Oriented x3

Marked

Stands out

Unremarkable

Normal

Auscultation

Listen

Percussion

To hit and listen for resulting sound

Palpation

Feel

Impression

Assessment

Diagnosis

What they believe pt has

Differential Diagnosis

List of conditions on what the pt may have based on symptoms/results

Benign

Safe

Malignant

Dangerous, a problem

Degeneration

Worsening

Remission

Improving, most used to describe cancer - this does NOT mean cured

Idiopathic

No known specific cause

Localized

Stays in certain part of body

Systemic/Generalized

All over the body, or most of it

Prognosis

Chances for it to get worse/better

Occult

Hidden

Lesion

Diseased tissue

Recurrent

Have again

Sequela

Problem resulting from injury/disease

Pending

Waiting for

Pathogen

Organism causing the problem

Morbidity

Risk for being sick

Mortality

Risk of dying

Etiology

The cause

Disposition

What happened to pt at end of visit - where pt went after visit

Discharge

“Unload”

1. Send home

2. Fluid coming out ofbody

Palliative

Treating symptoms not getting rid of the cause

Observation

Watch, keep an eye on

Reassurance

Tell pt problem is not serious cause of concern

Supportive Care

Treating symptoms to make pt feel better

Sterile

Clean, germ-free conditions

Prophylaxis

Preventative treatment

Proximal

Closer to center

Distal

Further away from center

Lateral

Out to side

Medial

Towards the middle

Ventral/Antral/Anterior

Front

Doral/Posterior

Back

Cranial

Towards the top

Caudal

Towards the bottom

Superior

Above

Inferior

Below

Prone

Lay on stomach

Supine

Lay on back

Contralateral

Opposite side

Ipsilateral

Same side

Unilateral

One side

Bilateral

Both sides

Dorsum

Top of hand or foot

Plantar

Sole of foot

Palmar

Palm of hand

Sagittal

Divides body, L & R

Coronal

Divides the body, Front & Back

Transverse

Divides the body, Top & Bottom

Physician

Skilled health provider who graduated medical school (MD or OD)

Pediatrician

Physician specialized in child care

Surgeon

Physician specialized in surgical operations or procedures