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Ch.2 Health records

Intro to Health Records

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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