TERMINOLOGY USED IN DOCUMENTATION

TERMS DEFINITION

Abduction To move away from midline

Abraded Scraped or wear away by friction or erosion.
Acetonuria Acetone in urine
Adduction To move towards the midline
Afebrile Without fever
Albuminuria Albumin in the urine
Ambulatory Walking
Amenorrhea Absence of menstruation
Amnesia Loss or defective memory
Ankyloses Stiff joint
Anorexia Loss of appetite
Anus / Anal Rectum or the opening at the end of the alimentary canal through which solid
waste matter leaves the body.
Apnea Short periods when breathing has ceased
Anuria Total suppression of urination
Arthritis Inflammation of joints
Asphyxia Suffocation, a condition arising when the body is deprived of oxygen,
causing unconsciousness or death.
Atrophy Wasting, result of the degeneration of cells
Auscultate To listen for sounds
Bradycardia Heartbeat less than 60 beats per minute
Cheyne-stoke respiration Increasing dyspnea, characterized by progressively deeper, and sometimes
faster breathing
Choluria Bile in the urine
Clonic tremor rhythmical jerking of the body or parts of the body
Concave Having an outline or surface that curves inward like the interior of a circle or
sphere. like an hourglass.
Conjunctivitis Inflammation of the conjunctiva
Convex Describes shapes that curve outward, like a football (or a rugby ball).
Coryza Watery drainage from nose
Cyanotic Bluish in color due to poor oxygenation
Defecation Bowel movement
Dental caries Decay of the tooth
Dentures False teeth
Diarrhea Excessive or frequent defecation
Diplopia Double vision
Distended Appears swollen due to pressure from inside; bloated.
Diuresis Large amount of urine voided
Dorsal recumbent Lying on back, knees flexed and apart
Dysmenorrhea Painful menstruation
Dysrhythmia/Arrhythmia Abnormal heart rhythm
Dysuria Painful urination
Ectomorph Is a typical skinny guy, have a light build with small joints and lean muscle.
Usually have long thin limbs with stringy muscles. Shoulders tend to be thin with
 little width.
Edematous Puffy, swollen
Emaciated Thin, underweight
Emetic Agent given to produce vomiting
Endomorph generally have a smooth, round body, medium-large bone structure, small
shoulders and shorter limbs.
Epistaxis Nosebleed
Eructation Belching
Erythema Redness
Eupnea Normal breathing
Excoriation Raw surface
Exophthalmos Abnormal protrusion of eyeball
Extension To straighten
Fatigue Tired
Febrile "related to fever."
Feigned Pretended
Fetid Foul
Fixed Motionless
Flaccid Soft, flabby
Flatus/flatulence Gas in the digestive tract
Flexion Bending
Flushed Pinkish or hot
Fowler’s position Semi-erect, knee flexed, head of bed elevated at 40 – 50 degrees
Gavage Forced feeding through tube passed into stomach
Glycosuria Glucose in the urine
Guaiac Test for occult blood
Gustatory Dealing with taste
Heliotherapy Using sunlight as a therapeutic agent
Hematemesis Blood in vomitus
Hematochezia Bright red blood in the stool, usually from the lower gastrointestinal tract -- the
colon or rectum or from hemorrhoids.
Hematuria Blood in the urine
Hemiplegia Paralysis of one side
Hemoglobinuria Hemoglobin in the urine
Hemoptysis Spitting of blood
Horizontal Flat, plane
Hydrotherapy Using water as a therapeutic agent
Hyperactive
Hyperpnea Rapid breathing
Hyperthermia is a condition where an individual’s body temperature is elevated beyond normal
Hypertonic Greater concentration or number of solute particles outside a membrane than
there are inside it body fluids, solution with higher osmotic pressure than another
solution
Hypothermia occurs when your body loses heat faster, low body temperature
Hypoactive
Hypotonic solutions have more water than a cell, will fill up with water and then burst
Infrequent Not often
Insomnia Inability to sleep
Instillation Pouring into a body cavity
Intermittent Starting and stopping, not continuous
Intradermal Within or through the skin
Intramuscular Within or through the muscle
Intraspinal Within or through the spinal canal
Intravenous Within or through the vein
Involuntary/incontinent Unable to control bowel or bowel
Isotonic Having the same tonicity or concentration as body fluids
Jack-knife position Prone with hips over break in table and feet below level of head
Jaundice Yellowish (skin) in color
Knee-chest position In face down position resting on knees and chest
Kyphosis Hump back, concavity of the spine
Labored Difficult, requires an effort
Laceration Torn, broken
Lateral position On the side, knee flexed
Lithotomy position On back, buttocks near the edge of table, knees well-flexed and separated
Lochia Drainage from the vagina after delivery
Lordosis Sway back convexity of the spine
Manipulate/manipulation To handle
Menopause Cessation of menstruation
Menorrhagia abnormally heavy or prolonged bleeding, Profuse menstruation
Mesomorph has a large bone structure, large muscles and a naturally athletic physique
Metrorrhagia Uterine bleeding at irregular intervals, particularly between the expected menstrual
periods.
Moist Wet
Monoplegia Paralysis of the limb
Mucopurulent Drainage containing mucous and pus
Mydriassis Dilation of the pupil of the eye
Myopia Nearsightedness
Myosis Contraction of pupil
Nausea Desire to vomit
Necrosis Death of tissue
Nocturia Frequent voiding at night
Objective data medical professionals obtain through observations by seeing, hearing,
smelling and touching, SIGN
Occipital Back of the head
Oliguria Scanty urination less than 400 ml in 24 hours
Orthopnea Inability to breathe or difficulty breathing when lying down
Palliative Offering temporary relief
Pallor White/pale
Palpate To feel with hands or fingers
Palpitation is the sensation that your heart has skipped a beat or added an extra beat. It may feel
like your heart is racing, pounding, or fluttering.
Paraplegia Paralysis of the legs
Paroxysm Spasms or convulsive seizures
Paroxysmal Coming in seizures
Pediculosis Lice
Percussion To strike
Persistent Lasting over a long time
Petechia Small rupture of blood vessels
Photophobia Sensitive to light
Photosensitivity Skin reaction caused by exposure to sunlight
Pigmented Containing color
Polyuria Increased amount of voiding
Prodromal syndrome is not a diagnosis, symptoms that may precede the onset of an illness.
Profuse/copious Large amount
Projectile Ejected or projected some distance
Pronation To turn downward
Prone On abdomen, face turned to one side
Prophylactic Preventive
Protruding Extends outward
Pruritus Itchiness
Ptosis Drooping eyelid
Purulent Drainage containing pus
Pyrexia Elevated temperature
Pyuria Pus in the urine
Radiating Spread to distant area
Radiotherapy Using x-ray or radium as a therapeutic agent
Rales, Crackles Abnormal breath sounds
Rapid Quickly
Rhinorrhea Runny nose or nasal discharges
Rotation To move in circular pattern
Sanguineous Bloody drainage
Scanty Small amount
Semi-Fowler’s position Semi-erect, head elevated 30 – 40 degrees
Sprain Wrenching of joint
Stertorous Snoring
Stethoscope Instrument used for auscultation
Strabismus Squinting
Stuporous Partial unconsciousness
Subcutaneous Under the skin
Subjective are information from the client's point of view, perceived by person (“symptoms”),
including feelings, perceptions, and concerns obtained through interviews.
Sudden onset Started all at once
Superficial On the surface only
Supination To turn upward
Suppurating Discharge pus
Syncope Fainting
Syndrome Group of symptoms
Tachycardia Fast heartbeat, greater than 100 beats per minute (bpm)
Tenacious Tough and sticky
Thready Barely perceptible
Tinnitus Ringing noise in the ear
Tonic tremor Continuous shaking
Trendelenburg position Flat on back with pelvis higher than head, foot of bed elevated 6 inches
Tympanic, Tympanitic Bell-like resonant, distention of abdomen due to presence of gas or air in intestine or
peritoneal cavity
Urticarial Hives or wheals, eruption of skin or mucous membrane
Vertigo Dizziness
Vesicle Fluid-filled blister
Visual acuity Sharpness of vision
Void, Micturate To urinate or pass urine