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Q
every x (e.g. Q4hr mean every 4 hours or Q3 days means every 3 days)
cv
cardiovascular
Subjective (Blue)
information received by the health care professional that is in the patient’s own words (e.g. how long the problem has been occurring, the quality of the problem, and factors that may make the problem better or worse)
Objective (Red)
data collected during the medical visit (e.g. physical exam, laboratory results, and imaging studies all contribute to the data)
Assessment (Yellow)
diagnosis or possible diagnosis by the health care provider who determines the assessment using all the information during the medical visit
Plan (Green)
treatment or follow-up for the patient (e.g. medication, physical therapy, or a procedure)
Review of Systems (ROS)
description of individual body systems in order to discover any symptoms not related to the main problem or chief complaint
Social History
a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
First line of prescription form
Name and strength of the medicine
Second line of prescription form
Marked “Sig,” contains patient’s instructions
Third line of prescription form
Marked “Dispense,” tells the pharmacist how much medicine to give the patient
Fourth line of prescription form
Mentions how many refillls are available for the prescription
Last line of prescription form
Health care provider’s signature
Clinic Note
medical professional documents a visit
HEENT
head, eyes, ears, nose and throat
NKDA
no know drugs allergies
Consult Note
physician (usually a specialist) provides an expert opinion on a more challenging problem
Emergency Department Note
ED medical staff documents an emergency department visit
Admission Summary
hospital medical professional documents the admission of a patient to the hospital
Discharge Summary
medical professional describes when and why the patient was admitted; documents a longer stay
Operative Report
surgeon documents a surgery in detail
Daily Hospital Note/Progress Note
medical professional documents daily hospital visit
Radiology Report
radiologist explains reason for image, how image was performed, what was seen on image, radiologist’s asssessment; sometimes a recommendation
Pathology Report
pathologist provides reasons for test, what was seen on the test and an assessment
Prescription
medical professional provides directions for a medication
Acute
Started recently, is sharp, or a severe problem
Chronic
Going on for a while
Exacerbation
Getting worse
Abrupt
Suddenly
Febrile
With fever
Afebrile
Without fever
malaise
Not feeling well
Progressive
More and more
Symptom
What a patient feels
Noncontributory
Not related to this specific problem
Lethargic
Decrease in level of consciousness
Genetic
Runs in the family
Hereditary
Runs in the family
Alert
Able to answer questions, responsive, interactive
Oriented
Aware of who they are, where they are and the current time
Marked
Stands out
Unremarkable
Normal
Auscultation
Listen
Percussion
To hit something and hear resulting sound, feel resulting vibration
Palpation
Feel
Impression
Assessment
Diagnosis
Identification of a problem
Differential diagnosis
List of possible causes of a problem
Benign
Safe
Malignant
Dangerous
Degeneration
Getting worse
Etiology
The cause
Remission
Improving, but not cured
Idiopathic
No specific cause, it just happens
Localized
Stays in a certain part of the body
Systemic/generalized
All over body (or most of it)
Morbidity
Risk for being sick
Mortality
Risk for dying
Prognosis
Chance of getting better or worse
Occult
Hidden
Pathogen
Organism that causes the problem
Lesion
Diseased tissue
Recurrent
To have again
Sequelae
Problem resulting from a disease or injury
Pending
Waiting
Disposition
What happens at the end
Discharge
Flowing of a fluid OR to send home
Prophylaxis
Preventive treatment
Pallitiative
Treating the symptoms but not getting rid of the cause
Observation
Watch, keep an eye on
Reassurance
Tell the patient that the problem is not serious or dangerous
Supportive care
Treat symptoms and make the patient feel better
Sterile
Clean, germ free
Proximal
Towards the center
Distal
Away from the center
Lateral
Out to the side
Medial
Toward the middle
Ventral
The front
Antral
The front
Anterior
The front
Dorsal
The back
Posterior
The back
Cranial
Toward the top
Caudal
Toward the bottom
Superior
Above
Inferior
Below
Prone
Laying down on stomach
Supine
Laying down on back
Dorsum
Top or back of the hand or foot
Plantar
Bottom of foot
Palmar
Palm of the hand
Contralateral
Opposite side
Ipsilateral
Same side
Unilateral
One side
Bilateral
Both sides
Sagittal
Divides body right and left
Coronal
Divided body front and back
Transverse
Divides body top and bottom
CCU
coronary care unit
ECU
emergency care unit