HLTH 2300 Lecture 2: Chapter 2 - Introduction to Health Records

16 views13 pages
18 Feb 2019
Department
Course
Professor
Acquiring medical language chapter 2
2.1 The SOAP Method
SOAP: an acronym that stands for the four general parts of a medical note
Subjective
Subject to how a patient experiences and personally describes his/her
problem as well as personal and family medical histories… including
the duration of the problem, quality of the problem, and
exacerbating/relieving factors for that problem
Main reason for the health visit
Description of the problem
Timing of the problem
Previous medical problems or surgeries
Family health problems that might relate
Current medications and allergies
§
Objective
Patient's physical exam, laboratory findings, and imaging studies
§
1:18 PM
Unlock document

This preview shows pages 1-3 of the document.
Unlock all 13 pages and 3 million more documents.

Already have an account? Log in
Patient's physical exam, laboratory findings, and imaging studies
performed at the visit
§
Assessment
Health care provider formulates a logical analysis…diagnosis,
identification of a problem, list of possibilities (differential
diagnosis)
§
Plan
Course of action consistent with his/her assessment…treatment with
medicine or a procedure or collecting further data
§
2.2 Common Terms in Medicine
Future second-nature words
Commonly used medical words not necessarily based on ancient languages
You will use them so often that they will become part of your normal
vocabulary
General subjective terms
Term
Definition
Acute
It just started recently or is a sharp, severe
symptom
Chronic
It has been going on for a while now
Exacerbation
It is getting worse
Abrupt
All of a sudden
Febrile
To have a fever
Afebrile
To not have a fever
Malaise
Not feeling well
Progressive
More and more each day
Symptom
Something a patient feels
Noncontributory
Not related to this specific problem
Lethargic
A decrease in level of consciousness; in a
medical record, this is generally an indication
that the patient is really sick
Genetic/hereditary
It runs in the family
General objective terms
Term
Definition
Alert
Able to answer questions; responsive; interactive
Oriented
Being aware of who he or she is, where they are,
Unlock document

This preview shows pages 1-3 of the document.
Unlock all 13 pages and 3 million more documents.

Already have an account? Log in
Oriented
Being aware of who he or she is, where they are,
and the current time; a patient who is aware of all
three is "oriented x 3"
Marked
It really stands out
Unremarkable
Another way of saying normal
Auscultation
To listen
Percussion
To hit something and listen to the resulting sound
or feel for the resulting vibration; drums are a
percussion instrument
Palpation
To feel
General assessment terms
Term
Definition
Impression
Another way of saying assessment
Diagnosis
What the health care professional thinks the
patient has
Differential diagnosis
A list of conditions the patient may have
based on the symptoms exhibited and the
results of the exam
Benign
Safe
Malignant
Dangerous; a problem
Degeneration
To be getting worse
Etiology
The cause
Remission
To get better or improve; most often used
when discussing cancer; remission does not
mean cure
Idiopathic
Not known specific cause; it just happens
Localized
Stays in a certain part of the body
Systemic/generalized
All over the body (or most)
Morbidity
The risk for being sick
Mortality
The risk for dying
Prognosis
The chances for things getting better or
worse
Occult
Hidden
Unlock document

This preview shows pages 1-3 of the document.
Unlock all 13 pages and 3 million more documents.

Already have an account? Log in

Get OneClass Notes+

Unlimited access to class notes and textbook notes.

YearlyBest Value
75% OFF
$8 USD/m
Monthly
$30 USD/m
You will be charged $96 USD upfront and auto renewed at the end of each cycle. You may cancel anytime under Payment Settings. For more information, see our Terms and Privacy.
Payments are encrypted using 256-bit SSL. Powered by Stripe.