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DX, Treatment

Diagnosis, Treatment and Therapy

Diagnoses (diagnosis, Dx) - the act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.
Treatment (Tx)- the active manner of treating a patient medically or surgically.
Empiric treatment- medical treatment that is given on the basis of the provider’s observations and experience
Prophylactic treatment (prophylaxis)- a measure taken to maintain health and prevent the spread of disease. “preventive treatment of disease”
Active treatment- treatment directed immediately to the cure of the disease or injury
Therapy- is the attempted remediation of a health problem, usually following a diagnosis. It’s synonymous with treatment in the medical field
H&P = History and Physical
HEENT = head, eyes, ears, nose, throat
SOAP- acronym for subjective data, objective data, assessment, plan (the way progress notes are organized)
Home Medication(s) = medication(s) patient take at home
Active Inpatient Medication(s)– medication(s) patient is prescribed during hospital stay
MAR = Medication Administration Record
EMAR = Electronic Medication Administration Record CCHS EMAR is located in Power Chart
Created by: wallace263