Clinical Words To Use In Progress Notes Pdf
Clinical progress notes are an essential part of medical documentation. They are used to track the patient's progress and ensure that the treatment plan is effective. As a healthcare professional, it's important to use appropriate clinical words in your progress notes to provide accurate information to other healthcare providers. This article will provide you with a comprehensive list of clinical words to use in progress notes PDF.
What are progress notes?
Progress notes are documents that healthcare professionals use to record a patient's medical status and treatment plan. They typically include a summary of the patient's condition, any updates on their treatment, and any changes to their medication or other therapies.
Progress notes are an important part of the medical record because they allow healthcare professionals to communicate with each other and ensure that the patient is receiving the best possible care. They are also essential for legal and financial purposes, as they provide a complete record of the patient's medical history.
Why use clinical words in progress notes?
Clinical words are specific medical terms that healthcare professionals use to describe a patient's condition and treatment plan. Using clinical words in progress notes ensures that other healthcare providers can understand the information provided and make informed decisions about the patient's care.
Clinical words are also important for legal and financial purposes, as they provide an accurate and detailed record of the patient's medical history.
List of clinical words to use in progress notes PDF
Here is a comprehensive list of clinical words to use in progress notes PDF:
- Abnormal
- Abscess
- Acute
- Adverse reaction
- Allergic
- Anemic
- Anxiety
- Arrhythmia
- Arthralgia
- Atherosclerosis
- Auscultation
- Benign
- Bilateral
- Bronchitis
- Cardiomegaly
- Chronic
- Comatose
- Conjunctivitis
- Constipation
- Contusion
- Cystic
- Deep vein thrombosis
- Dehydration
- Diabetes
- Diaphoresis
- Diarrhea
- Disoriented
- Dysphagia
- Dyspnea
- Elevated
- Emphysema
- Endocarditis
- Enlarged
- Erythema
- Fever
- Fibrosis
- Fluctuating
- Fracture
- Gastroenteritis
- Genitourinary
- Glaucoma
- Heartburn
- Hypertension
- Hypotension
- Inflammation
- Infrequent
- Injury
- Insomnia
- Jaundice
- Laceration
- Laryngitis
- Lesion
- Leukocytosis
- Leukopenia
- Lightheadedness
- Malaise
- Malignant
- Meningitis
- Metastasis
- Mucoid
- Mucus
- Myocardial infarction
- Nausea
- Necrosis
- Nodule
- Normal
- Obstruction
- Oral candidiasis
- Osteoarthritis
- Osteoporosis
- Pallor
- Palpitation
- Pancreatitis
- Pneumonia
- Polydipsia
- Polyuria
- Rheumatoid arthritis
- Sepsis
- Sinusitis
- Stenosis
- Stress test
- Stroke
- Syncope
- Tachycardia
- Tenderness
- Thrombocytopenia
- Tinnitus
- Trauma
- Tremors
- Ulcer
- Urticaria
- Vasodilation
- Vertigo
- Vesicular
- Viral
- Wheezing
Conclusion
Using clinical words in progress notes is important for accurate and effective communication between healthcare professionals. By using the clinical words listed above, you can provide detailed and specific information about your patient's medical history and current condition. Remember to use these words appropriately and in context to ensure that your progress notes are informative and useful to other healthcare providers.
