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Chapter 4
The Medical Record
| Question | Answer |
|---|---|
| H & P | History and Physical Cornerstone of patient care documentation of patient history and physical examination findings Required before hospital admission (for surgery) |
| Hx | History record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects and habits |
| subjective information | information obtained from the patient including his or her personal perceptions |
| CC | Chief Complaint |
| c/o | complains of patient's description of what brought him or her to the doctor or hospital;it is usually brief and is documented in the patient's own words indicated within quotes |
| HPI (PI) | History of present illness(Present Illness) amplification of the cheif complaint recording details of the duration and severity of the condition (how long the patient has had the complaint and how bad it is) |
| Charta | from the Latin charta which is a kind of paper made from papyrus. |
| R/O | rule out used to indicate a differential diagnosis when two or more possible diagnoses are in question |
| Sx | Symptom subjective evidence (from the patient) that indicates an abnormality |
| PMH (PH) | Past Medical History (Past History) a record of information about the patient's past illnesses starting with childhood, including surgicla operations, injuries, physical defects, medications and allergies |
| UCHD | usual childhood diseases an abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood (measels, chickenpox, mumps) |
| NKA | no known allergies |
| NKDA | no known drug allergies |
| FH | Family History state of health of immediate family members |
| A & W | alive and well |
| L & W | Living and well |
| SH | Social History a record of the patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol |
| OH | Occupational History a record of work habits that may involve work-related risks |
| ROS (SR) | Review of systems (Systems Review) a documenattion of the patient's response to questions organized by a head-to-toe review of the function of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned) |
| objective information | facts and observations noted |
| PE (Px) | Physical Examination documentation of a physical examination of a patient, including notations of positive and negative objective findings |
| HEENT | head, eyes, ears, nose, throat |
| NAD | no acute distress, no appreciable disease |
| PERRLA | pupils equal, round and reactive to light and accomodation |
| WNL | within normal limits |
| Dx | Diagnosis |
| IMP | Impression |
| A | Assessment identification of a disease or condition after evaluation of the patient's history, symptoms, signs and results of laboratory tests and diagnostic procedures |
| P | Plan (also referred to as recommendation or disposition) outline of the treatment plan designed to remedy the patient's condition, which includes instructions to the patient, orders for medications, diagnostic tests or therapies |
| POMR | Problem oriented medical record Introduced in the 60's it is a medical record in which all information is linked to specific problems |
| Database | patient's history, physical exam and diagnostic test results. From the database the problem is identified and a plan developed to address it. |
| Problem List | Directory of the patient's problems; each problem is listed and often assigned a number;problems include 1. specific diagnosis 2.sign or symptom 3.abnormal diagnostic test result 4.any other problem that may influence health or well being |
| Initial plan | The strategy employed to resolve each problem as listed |
| Diagnostic Plan | orders are given for specific diagnostic testing to confrm suspicions |
| Therapeutic Plan | Goals for therapy are specified |
| Patient Education | instructions or communicated to the patient are notated |
| Progress notes | documentations of the progress concerning each problem are organized using the SOAP format |
| SOAP | Subjective, Objective, Assessment, Plan S-that which the patient describes O-observable information A-patient's progress and evaluation of the plan's effectiveness P-decision to proceed or alter the plan strategy |
| consent form | document signed by the patient or legal guardian giving permission for medical or surgical care |
| informed consent | consent of a patient after being informed of the risks and benefits of a procedure and alternatives-often required by law when a reasonable risk is involved |
| physician's orders | a record of all orders directed by the attending physician |
| diagnostic tests/laboratory reports | records of results of various tests and procedures used in evaluating and treating a patient (laboratory tests, x-rays) |
| nurse's notes | documentation of patient care by the nursing staff (flow sheets and graph's are often used to display recordings of vital signs and other monitored procedures) |
| Physician's progress notes | physician's daily account of patient's response to treatment, including results of tests, assessment and future treatment plans |
| ancillary reports | misc. records of procedures or therapies provided during a patient's care (physical therapy, respiratory therapy) |
| consultation report | report filed by a specialist asked by the attending physician to evaluate a difficult case;note: a patient may also see another physician in consultation as an outpatient(in a medical office or clinic) |
| operative report (op report) | surgeon's detailed account of the operation including the method of incision, technique, instruments used, types of sutures, method of closure, and the patient's responses during the procedure and at the time of transfer to recovery |
| pathology report | report of the findings of a Pathologist after the study of tissue (biopsy) |
| Anesthesiologist's report | report of the details of anesthesia during surgery, including drugs used, dose and time given and records given indicating monitoring of the patient's vital status throughout the procedure |
| discharge summary, clinical resume, clinical summary, discharge abstract | 4 terms that describe an outline summary of the patient's hospital care, including date of admission, diagnosis, course of treatment, final diagnosis, and date of discharge |
| JCAHO | Joint commission on accreditation of Healthcare Orginizations requires that all medical facilities publish a list of authorized abbreviations |
| CCU | coronary (cardiac) care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ICU | Intensive Care Unit |
| IP | inpatient (a registered bed patient) |
| OP | outpatient |
| OR | operating room |
| PACU | postanesthetic care unit |
| PAR | postanesthetic recovery |
| post-op/postop | postoperative (after surgery) |
| pre-op/preop | preoperative (before surgery) |
| RTC | return to clinic |
| RTO | return to office |
| BRP | bathroom privileges |
| CP | chest pain |
| DC*, D/C* | discharge, discontinue |
| ETOH | ethyl alcohol |
| L -circled | Left |
| R-circled | Right |
| pt | patient |
| RRR | regular rate and rhythm |
| SOB | shortness of breath |
| Tr | treatment |
| Tx | treatment or traction |
| VS | vital signs |
| T | temp |
| P | pulse |
| R | respiration |
| BP | blood pressure |
| Ht | height |
| Wt | weight |
| WDWN | well developed and well nourished |
| y.o. | year old |
| # | number or pound |
| ♀ | Female |
| ♂ | Male |
| º | degree or hour |
| ↑ | Increased |
| ↓ | Decreased |
| θ | None or negative |
| (blank) | standing |
| (blank) | sitting |
| (blank) | lying |
| CBC | complete blood count (Diagnostic test) used to R/O a particular condition or as a general health inquiry |
| Urinalysis (UA) | (Diagnostic test) used to R/O a particular condition or as a general health inquiry |
| Wilhelm Roentgen | discovered x-rays in 1895 |
| Radiography (X-Ray) | a modality using x-rays(ionizing radiation) to provide images of the body's anatomy to diagnose a condition or impairment |
| CT (CAT) | Computed Tomography or Computed Axial Tomography a radiologic procedure that uses a machine called a scanner to examine a body site by taking cross sectional x-ray films in a full circle rotation.Computer converts the x-rays to a 3 dimensional(3D) picture |
| Nuclear medicine imaging or Radionuclide Organ Imaging | uses an injected or ingested radioactive isotope also called radionuclide a camera detects and produces an image of the distribution of the gamma rays. Useful for size, shape, location and function of body organs |
| Radionuclide | chemical that has been tagged with radioactive compounds that emit gamma rays |
| MRI | Magnetic Resonance Imaging technique using magnetic fields and radiofrequency waves to visualize anatomical structures in the body used to examine soft tissues like joints, brain and spinal cord |
| MRA | Magnetic resonance angiography applies MR technology in the study of blood flow |
| Sonography | Diagnostic ultrasound uses high frequency sound waves to visualize body tissues such as abdomen, reproductive organs,Thyroid and cardiovascular systems. Produces moving images on a monitor |
| Contrast | enhances visualization of anatomical structures.Includes Barium, iodinated compounds, gasses. May be injected, swallowed or introduced through a catheter or enema |
| Normal | Latin word normalis meaning a carpenter's square. Meaning a rule or patterns |
| Benign versus malignant | Latin benignus meaning kind and malignus meaning bad origin |
| acute | sharp;having intense, often severe symptoms and a short course |
| chronic | a condition developing slowly and persisting over time |
| benign | mild or non cancerous |
| malignant | harmful or cancerous |
| degeneration | gradual deterioration of normal cells and body functions |
| degenerative disease | any disease in which there is deterioration of structure or function of tissue |
| diagnosis | determination of the presence of a disease based on the evaluation of symptoms, signs, and test findings (results)(dia=through;gnosis=knowing) |
| etiology | cause of a disease(etio=cause) |
| exacerbation | increase in severity of a disease with aggravation of symptoms (ex=out, acerbo=harsh) |
| remission | a period in which signs and symptoms stop or abate |
| febrile | relating to a fever (elevated temp) |
| gross | large;visible to the naked eye |
| idiopathic | a condition occuring without a clearly identified cause (idio=one's own) |
| localized | limited to a definite area or part |
| systemic | relating to the whole body rather than only a part |
| malaise | a feeling of unwellness, often the first indication of illness |
| marked | significant |
| equivocal | vague, questionable |
| morbidity | sick, a state of disease |
| morbidity rate | the # of cases of a disease in a given year;the ratio of sick to wellindividuals in a given population |
| mortality | the state of being subject to death |
| mortality rate | death rate;ratio of total # of deaths to total number in a given population |
| prognosis | foreknowledge;prediction of the likely outcome of a disease based on the general health staus of the patient along with knowledge of the usual course of the disease |
| progressive | the advance of a condition as signs and symptoms increase in severity |
| prophylaxis | a process or measure that prevents disease (pro=before;phylassein=to guard |
| recurrent | to occur again;describes a return of symptoms and signs after a period of quiescence (rest or inactivity) |
| sequela | a disorder or condition after,usually resulting from a previous disease or injury |
| sign | a mark;objective evidence of disease that can be seen or verified by an examiner |
| symptom | occurence;subjective evidence of disease that is perceived by the patient and often noted in his or her own words |
| syndrome | a running together;combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease. |
| noncontributory | not involved in bringing on the condition or result |
| unremarkable | not significant or worthy of noting |
| Metric | The most commonly used system of measuring in healthcare |
| meter (m) | length 39.37 inches |
| liter (L) | volume 1.0567 US quarts |
| gram (g or gm) | weight 15.432 grains |
| Drug | middle english dragge or dragge derived from French drogue meaning drug |
| apothecary system | one drop equaled one grain of wheat |
| cc | cubic centimeter 1cc=1mL |
| cm | centimeter 2.5cm=1 inch |
| g or gm | gram |
| kg | kilogram 1,000 gm 2.2 pounds |
| L | liter |
| mg | milligram 0.001 of a gram |
| ml, mL | milliliter 0.001 of a liter |
| mm | millimeter 0.001 of a meter |
| cu mm | cubic millimeter |
| fl oz | fluid ounce |
| gr | grain |
| gt | drop L.gutta=drop |
| gtt | drops |
| dr | dram 1/8 ounce |
| oz | ounce |
| lb or # | pound 16 ounces |
| qt | quart 32 ounces |
| tablet (tab) capsule (cap) | oral [per os(p.o.] {Oral} Sublingual (SL) {under the tongue} buccal {in the cheek} |
| suppository (suppos) | vaginal [per vagina(PV)] rectal {inserted in vagina}[per rectum(PR)]{inserted in rectum} |
| fluid | inhalation {inhaled through nose or mouth} |
| parenteral | by injection |
| intradermal (ID) | within the skin |
| intramuscular (IM) | within the muscle |
| intravenous (IV) | within the vein |
| subcutaneous (Sub-Q, SC*, SQ*) | under the skin |
| cream, lotion, ointment | topical (applied to the surface of the skin) |
| other delivery systems | transdermal {absorption of a drup through unbroken skin}, implant {a drug reservoir imbedded in the body to provide continual infusion of a medication} |
| Rx | symbol at beginning of prescription stands for recipe. Cross on the tail was a sign of Jupiter |
| Prescription | a written direction by a physician for dispensing or administering a medication to a patient, legal document |
| chemical name | name assigned to drug at the time it is invented in the laboratory, written to chemical structure |
| generic name | official, nonproprietary name |
| trade or brand name | manufacturer's name for a drug |
| q.d. | every day |
| q.o.d. | every other day |
| AS* | Left Ear {auris sinistra} |
| AD* | Right Ear {auris dextra} |
| AU* | Both ears {aures unitas} |
| OS* | Left Eye {oculus sinister} |
| OD* | Right Eye {oculus dexter} |
| OU* | both eyes {oculi unitas} |
| SC* or SQ* | subcutaneous |
| >* | greater than |
| <* | less than |
| ā | before |
| a.c. | before meals {ante cibum} |
| a.m. | before noon (ante meridiem} |
| b.i.d. | twice a day {bis in die} |
| d | day |
| h | hour {hora} |
| h.s. | at hour of sleep {hora somni} |
| noc. | night {noctis} |
| p lined at top | after {post} |
| p.c. | after meals {post cibum} |
| p.m. | after noon {post meridiam} |
| p.r.n. | as needed {pro re nata} |
| q lined at top | every {quaque} |
| q d * | every day {quaque die} |
| q h | every hour {quaque hora} |
| q 2 h | every 2 hours |
| q.i.d. | 4 times a day {quater in die} |
| q.o.d. | every other day {quaque altera die} |
| STAT | immediately {statim} |
| t.i.d. | 3 times a day {ter in die} |
| wk | week |
| yr | year |
| ad lib. | as desired {ad libitum} |
| amt | amount |
| aq | water {aqua} |
| B circled | bilateral |
| C | Celsius, centigrade |
| c lined at top | with {cum} |
| F | Fahrenheit |
| m circled | murmur |
| NPO | nothing by mouth {non per os} |
| per | by or through |
| p.o. | by mouth {per os} |
| PR | through rectum {per Rectum} |
| PV | through vagina {per Vagina} |
| q.n.s. | quantity not sufficient |
| q.s. | quantity sufficient |
| Rx | Recipe or prescription |
| Sig: | label;instruction to the patient {signa} |
| s lined at top | without {sine} |
| ss lined at top* | one half {semi} |
| w.a. | while awake |
| X | times or for { X 2 days} |
Created by:
christina_macenfish
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