Build the term from the word parts, using a root, and prefixes and/or suffixes

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Medical Records

A note in a medical record usually consists of 4 parts, abbreviated SOAP. These are:

  • Subjective -- Symptoms that the patient feels and tells to the medical professional
  • Objective -- Signs that the medical professional observes on the physical exam
  • Assessment -- The Diagnosis
  • Plan --Tests that may be ordered, or medications that may be prescribed.

please give ONE medical  term that might be found in each of these sections of a medical record.

Jul 12th, 2015

Thank you for the opportunity to help you with your question!

Subjective: Jaundice

Objective: Temperature of 98.6F

Assessment: Strep throat

Plan: Prescribe antibiotics

Please let me know if you need any clarification. I'm always happy to answer your questions.
Jul 12th, 2015

you did the assignment wrong

Jul 13th, 2015

Hi Monique,

I've actually audited medical records for Medicare/Medicaid compliance, so I am comfortable in the original answer I gave you.

If your assignment calls for a different answer than what the instructions imply, please let me know, and I'll redo it immediately.

Jul 13th, 2015

Here's a  example on how its suppose to look....

You are NOT writing a chart note .You are creating 4 medical terms.   Please read the chapter and use your textbook and your BRAIN only,  to do this!  It is entirely possible you might create terms that do not exist and that is OK.  It is nice to get real ones if you can,  but the point is to learn to work with the word parts!  In my example I am using the root for "esophagus" which is our swallowing tube (it goes from the throat to the stomach.)  You may give a small explanation IN YOUR OWN WORDS if you like.

S:  Dysphagiadys- Prefix meaning "bad, abnormal, painful or difficult." + phag/ (root meaning swallowing) + -ia (suffix meaning "condition of".) = painful and difficult swallowing.  This is what the patient was complaining of.

O:  Intraesophageal object.  intra- (prefix meaning "within") + esophag/  (root meaning esophagus) + "E" (combining vowel)  -al (suffix meaning pertaining to) = pertaining to within the esophagus.  The physician ordered an Xray and observed an object stuck within the swallowing tube.

A:  Esophageal obstruction by foreign body.   esophag/ (root meaning "esophagus") + "E" (combining vowel) + -al (suffix meaning "pertaining to") =  Pertaining to within the esophagus.  The swallowing tube is obstructed by a "foreign body" (which is simply something that does not belong there.)  "within" the esophagus.

P:  Esophagoscopy   esophag/ (root meaning esophagus) + "O" (combining vowel) + -scopy  (suffix meaning using an instrument to view)  = using an instrument to view the esophagus.   The physician will perform a procedure to look into the esophagus.

This is based on a true story from my practice.  This was a teenaged girl who had half a hot dog stuck in her esophagus!  The surgeon was able to remove it with the "esophagoscope."

Jul 13th, 2015

Your PLAN needs to be something that the doctor will do,  such as a procedure,  or it could be a class of medication,  or it could be a referral to a specific type of doctor.  In this case,  the "plan" might be to take a look inside the joint.  Can you figure out the term for that?  I would like for you to come back and "reply" to me,  with all the things I just asked for.  The reason is for you to learn!  Class,  I will be doing this same type of thing on many of the posts.  We will end up with everything PERFECT by the end of the week!

Jul 13th, 2015

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