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Chap2 Health Records

Health Records

TermDefinition
Chief Complaint Reason for the visit
History of Present Illness Story of the patients problem
Review of systems Description of individual body systems in order to discover any symptoms not directly related to the main problem.
Past Medical history Other significant past illnesses, like high blood pressure, asthma, or diabetes
Past surgical history any of the patient's past sugeries
Family history Any significant illnesses that run in the patients family
social history a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health
Alert Able to answer question; responsive; interactive
oriented being aware of who he or she is, aware he or she is and the current time, a patient who is aware of three is "oriented X3"
marked it really stands out
unremarkable another way of saying normal
Created by: jekgetz1