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Records the details of a patient’s care during a hospital stay |
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Prevention of disease or of a process that can lead to disease. |
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Return of symptoms after a period of quiescence |
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Report filed by a specialist who has been called in to discuss a difficult case with an attending physician |
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Term describing administration of a drug in the cheek |
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" Plan, recommendation, or disposition ( the “P” portion of the SOAP report)" |
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The part of the medical report that outlines strategies to treat the patient’s condition |
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Report that documents the procedures and treatments the patient has undergone |
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Abbreviation for “left ear” |
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Abbreviation for “right ear” |
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Abbreviation for “both ears” |
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Abbreviation for “right eye” |
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Abbreviation for “left eye” |
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Abbreviation for “both eyes” |
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Study of the cause of a disease |
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Occurring without identifiable cause |
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Referring to the body as a whole |
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Referring to a definite area or part |
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condition following as a consequence of a previous disease |
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Not significant or worthy of being noted |
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Syndrome (e.g. Irritable bowel syndrome) |
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Definition
"A collection of symptoms and signs associated with a disease process, that, taken as a whole, give a distinct picture of a particular disease " |
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Definition
Abbreviation for 4 times a day |
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Abbreviation for 2 times a day |
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Abbreviation for 3 times a day |
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Abbreviation for “as needed” |
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Abbreviation for “immediately” |
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Diagnosis—the determination of the presence of disease |
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Definition
"Using the SOAP format in a patient’s chart, the “A” (assessment) includes" |
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"Using the SOAP format in a patient’s chart, the “O”(objective) includes" |
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" Head, eyes, ears, nose, and throat" |
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Definition
The abbreviation for HEENT means |
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Definition
Examples of UCHD (usual childhood diseases) |
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“O” (objective) section of the SOAP format |
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Definition
"Using the SOAP format in a patient’s chart, the VS (vital signs) appear in which part" |
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“S” (subjective) section of the SOAP format |
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"Using the SOAP format in a patient’s chart, the patient’s description of the symptoms being experienced appears in which part?" |
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Applied to the surface of the skin |
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Abbreviation for “by mouth” |
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Abbreviation for “tablet” |
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Abbreviation for “capsule” |
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Term meaning under the tongue |
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Abbreviation for “every other day” |
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Having severe symptoms lasting only a short time |
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A condition that develops slowly and persists over a period of time |
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Abbreviation for “millimeter” |
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Abbreviation for a patient’s chief complaint |
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Abbreviation for “cubic centimeter” |
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PAR (post-anesthetic recovery) |
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Definition
Abbreviation for the place in which a patient recovers immediately after surgery |
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HPI (history of present illness) |
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Definition
Amplification of patient’s initial complaint that includes the duration and severity of the problem |
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Absorption of medication through unbroken skin |
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MRI (magnetic resonance imaging) |
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The diagnostic imaging technique that uses magnetic fields and radio waves to visualize anatomical structures |
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"Generic (E.g. Valium—brand name, diazepam—generic name)" |
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Definition
"Official, common name that refers to a drug’s chemical identity, as opposed to a brand name used by a particular company for marketing purposes." |
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Manufacturer’s name for a specific drug |
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Condition in which the signs and symptoms advance with increased severity |
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acute flare-up of symptoms |
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Abbreviation for “treatment” |
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"In military time, twenty-two hundred hours is " |
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Abbreviation of the term used to denote an evaluation of all body systems |
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Abbreviation that indicates a “differential diagnosis” (used when one or more diagnoses are in questions; a differential diagnosis is a working list of possibilities that a physician uses in the process of diagnosing a specific disease) |
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diagnostic imaging modality which uses a gamma camera |
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"Portion of patient history that records hobbies, interests, and/or tobacco, drug, or alcohol use" |
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Portion of patient history that records the state of health of immediate family members |
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Imaging modality that uses high frequency sound waves instead of ionizing radiation |
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H&P (history and physical) |
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Report that is required before admission for surgery |
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Substance used in imaging procedures to enhance the visualization of internal structures |
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x-ray imaging modality that examines body structures using a computer to construct a series of cross-sectional scans along a single axis |
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Metric unit that measures length |
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Metric unit that measures volume |
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Metric unit that measures weight |
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