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Willis Med Terms: Med. Record
Medical terms Chapter2: The Medical Record
69
Medical
Undergraduate 1
08/26/2006

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Term
Nurse’s notes
Definition
Records the details of a patient’s care during a hospital stay
Term
prophylaxis
Definition
Prevention of disease or of a process that can lead to disease.
Term
malignant
Definition
Harmful or cancerous
Term
recurrent
Definition
Return of symptoms after a period of quiescence
Term
Consultation report
Definition
Report filed by a specialist who has been called in to discuss a difficult case with an attending physician
Term
subcutaneous
Definition
Beneath the skin
Term
buccal
Definition
Term describing administration of a drug in the cheek
Term
" Plan, recommendation, or disposition ( the “P” portion of the SOAP report)"
Definition
The part of the medical report that outlines strategies to treat the patient’s condition
Term
Ancillary report
Definition
Report that documents the procedures and treatments the patient has undergone
Term
AS
Definition
Abbreviation for “left ear”
Term
AD
Definition
Abbreviation for “right ear”
Term
AU
Definition
Abbreviation for “both ears”
Term
OD
Definition
Abbreviation for “right eye”
Term
OS
Definition
Abbreviation for “left eye”
Term
OU
Definition
Abbreviation for “both eyes”
Term
etiology
Definition
Study of the cause of a disease
Term
idiopathic
Definition
Occurring without identifiable cause
Term
systemic
Definition
Referring to the body as a whole
Term
localized
Definition
Referring to a definite area or part
Term
morbidity
Definition
Diseased state
Term
sequela
Definition
condition following as a consequence of a previous disease
Term
unremarkable
Definition
Not significant or worthy of being noted
Term
Syndrome (e.g. Irritable bowel syndrome)
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 "
Term
qid
Definition
Abbreviation for 4 times a day
Term
bid
Definition
Abbreviation for 2 times a day
Term
tid
Definition
Abbreviation for 3 times a day
Term
PRN
Definition
Abbreviation for “as needed”
Term
STAT
Definition
Abbreviation for “immediately”
Term
Diagnosis—the determination of the presence of disease
Definition
"Using the SOAP format in a patient’s chart, the “A” (assessment) includes"
Term
Observable facts
Definition
"Using the SOAP format in a patient’s chart, the “O”(objective) includes"
Term
" Head, eyes, ears, nose, and throat"
Definition
The abbreviation for HEENT means
Term
Measles and chickenpox
Definition
Examples of UCHD (usual childhood diseases)
Term
“O” (objective) section of the SOAP format
Definition
"Using the SOAP format in a patient’s chart, the VS (vital signs) appear in which part"
Term
“S” (subjective) section of the SOAP format
Definition
"Using the SOAP format in a patient’s chart, the patient’s description of the symptoms being experienced appears in which part?"
Term
topical
Definition
Applied to the surface of the skin
Term
po
Definition
Abbreviation for “by mouth”
Term
tab
Definition
Abbreviation for “tablet”
Term
cap
Definition
Abbreviation for “capsule”
Term
sublingual
Definition
Term meaning under the tongue
Term
qod
Definition
Abbreviation for “every other day”
Term
acute
Definition
Having severe symptoms lasting only a short time
Term
chronic
Definition
A condition that develops slowly and persists over a period of time
Term
mm
Definition
Abbreviation for “millimeter”
Term
CC (capital letters)
Definition
Abbreviation for a patient’s chief complaint
Term
cc (small-case letters)
Definition
Abbreviation for “cubic centimeter”
Term
PAR (post-anesthetic recovery)
Definition
Abbreviation for the place in which a patient recovers immediately after surgery
Term
HPI (history of present illness)
Definition
Amplification of patient’s initial complaint that includes the duration and severity of the problem
Term
transdermal
Definition
Absorption of medication through unbroken skin
Term
MRI (magnetic resonance imaging)
Definition
The diagnostic imaging technique that uses magnetic fields and radio waves to visualize anatomical structures
Term
"Generic (E.g. Valium—brand name, diazepam—generic name)"
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."
Term
Brand or trade name
Definition
Manufacturer’s name for a specific drug
Term
pound
Definition
The symbol # means
Term
progressive
Definition
Condition in which the signs and symptoms advance with increased severity
Term
exacerbation
Definition
acute flare-up of symptoms
Term
"tx, tr"
Definition
Abbreviation for “treatment”
Term
10:00 PM
Definition
"In military time, twenty-two hundred hours is "
Term
ROS (review of systems)
Definition
Abbreviation of the term used to denote an evaluation of all body systems
Term
r/o (rule out)
Definition
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)
Term
Nuclear medicine
Definition
diagnostic imaging modality which uses a gamma camera
Term
SH (social history)
Definition
"Portion of patient history that records hobbies, interests, and/or tobacco, drug, or alcohol use"
Term
FH (family history)
Definition
Portion of patient history that records the state of health of immediate family members
Term
ETOH (ethyl alcohol)
Definition
Abbreviation for alcohol
Term
Ultrasound (sonography)
Definition
Imaging modality that uses high frequency sound waves instead of ionizing radiation
Term
H&P (history and physical)
Definition
Report that is required before admission for surgery
Term
Contrast medium
Definition
Substance used in imaging procedures to enhance the visualization of internal structures
Term
CT (computed tomography)
Definition
x-ray imaging modality that examines body structures using a computer to construct a series of cross-sectional scans along a single axis
Term
meter
Definition
Metric unit that measures length
Term
liter
Definition
Metric unit that measures volume
Term
gram
Definition
Metric unit that measures weight
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