Chapter 2 Medical Records

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Across
  1. 4. able to answer questions (responsive, interactive)
  2. 6. this kind of health record note is for a new patient an is in SOAP format
  3. 7. another way of saying normal
  4. 9. (2 words) "pre-op" is the abbreviation for this
  5. 11. (2 words) the reason for the patient's visit
  6. 13. toward the bottom
  7. 14. the chances for things to get better or worse
  8. 16. this kind of plane divides the body from top to bottom
  9. 18. two types of these can be MDs or DOs
  10. 19. this kind of plane divides the body in slices right to left
  11. 20. stays in a certain part of the body
  12. 21. the sole of the foot
  13. 22. the top of the hand or foot
  14. 26. waiting for
  15. 27. safe
  16. 28. abbreviated with "Pt"
  17. 29. trained to removal blood from the body for diagnostic purposes
  18. 31. this person is trained to prepare and dispense medication
  19. 32. it really stands out
  20. 34. farther away from the center
  21. 36. risk of dying
  22. 38. extremely clean, germ-free conditions
  23. 39. a description of a normal heart on exam is abbreviated this...
  24. 40. (2 words)"PO" is the abbreviation that means...
  25. 41. this happens all of the sudden
  26. 42. this part of the exam could include a diagnosis
  27. 44. it has been going on for awhile now
  28. 45. to tell the patient that the problem is not dangerous
Down
  1. 1. this part of the SOAP note is how the patient describes what is going on
  2. 2. this type of health record note describes when and why the patient was admitted, and it documents a longer stay
  3. 3. closer in to the center
  4. 5. Its abbreviation is "T"
  5. 8. to listen
  6. 10. this part of a SOAP note comprises the patient's physical exam, any lab findings, and imaging studies
  7. 12. risk for bein sick
  8. 15. A location to deliver medication (abbrev. SC)
  9. 17. general feeling of not feeling very good
  10. 22. what happened to the patient after the visit (sent home, hospitalized, etc)
  11. 23. this type of health record note can be in the form of a letter to the PCP and it provides an expert opinion
  12. 24. trained in evaluating the nutritional status of a patient and developing an appropriate diet plan
  13. 25. below
  14. 26. treating the symptoms, but not getting rid of the cause
  15. 29. a treatment with a medicine or a treatment
  16. 30. to feel
  17. 31. this abbreviation describes other significant past illnesses like hypertension , asthma, diabetes
  18. 33. opposite side
  19. 35. there is no specific cause...it just happens
  20. 37. both sides
  21. 43. lying down on back