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Chap2 Health Records
Health Records
Term | Definition |
---|---|
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 |