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Ch.2 Health records
Intro to Health Records
| Term | Definition |
|---|---|
| Acute | it just started recently or is a sharp, severe symptom |
| Chronic | it has been going on for a while now |
| Exacerbation | It is getting worse |
| Abrupt | All of a sudden |
| Febrile | to have a fever |
| malaise | not feeling well |
| Progressive | more and more each day |
| symptom | something a patient feels |
| noncontributory | not related to the specific problem |
| lethargic | a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick |
| genetic/hereditary | runs in the family |
| Subjective | how a patient experiences and personally describes his or her problem as well as personal and family histories |
| Objective | the patients physical exam, any lab findings, and imaging studies performed at the visit |
| Assessment | could be a diagnosis, identification of the problem, or a list of possibilities for the diagnosis |
| Plan | could be the treatment with medicine or a procedure |
| Anatomic position | position that a person is standing facing forward, arms at the side with palms forward |
| lateral | out to the side |
| medial | toward the middle |
| Ventral/antral/anterior | the front |
| cranial | toward the top |
| caudal | toward the bottom |
| prone | lying down on the belly |
| supine | lying down on the back |
| unilateral | one side |
| bilateral | both sides |
| sagittal | right to left |
| coronal | front to back |
| transverse | top to bottom |
| Clinic Note | anytime a health care professional sees a patient in an office setting, he or she must document the visit. These notes always follow the SOAP method |
| Consult Note | A note from a visit to a specialist or consultant |
| Emergency Department Note | explains what happened to the patient during his or her stay in the ED |
| Admission Summary | upon admittance to the hospital, patients must provide a medical history and receive a physical exam. Detailed admission summaries are usually thorough notes that are heavy on the subjective and objective parts |
| Discharge summary | details when and why a patient was admitted. Includes how the patient felt when admitted, what happened during the stay, and what kind of follow-up the patient will have |
| Operative Report | documents in detail the procedure that was performed, the events that transpired the surgery, and the patients outcome from the surgery |
| Daily Hospital Note/ Progress Note | focuses on how the patients condition has changed since the previous note |
| Radiology Report | explains the reason for ordering a radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist's assessment. |
| Pathology Report | Mirrors the same style as the radiology note |
| Prescription | Does NOT follow the SOAP note format---Because it is the plan |
| ROS | Review of systems |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no know drug allergy |
| PE | Physical exam |
| Pt | patient |
| PCP | Primary care provider |
| SOB | Shortness of breath |
| HEENT | Heart, eyes, ears, nose and throat |
| PERRLA | Pupils are equal, round, and reactive to light and accommodation |
| NAD | No acute distress |
| CV | Cardiovascular |
| RRR | Regulare rate and rhythm |
| CTA | Clear to auscultation (normal sounding lungs) |
| WDWN | Well developed, well nourished |
| A&O | alert and oriented |
Created by:
ovjames
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