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Health Records

Definition
General assessment terms: impression, diagnosis, differential diagnosis, etiology vs. idiopathic, benign vs. malignant, remission
General assessment terms ( cont.): morbidity, mortality, prognosis, localized vs. systemic / generalized, pathogen, lesion, sequelae
General plan terms: disposition, observation, reassurance, supportive care, palliative
Common terms on health records- Body Planes and Orientation Distal, Proximal, Medial, Lateral, Midline, Right, Left, Superior, Inferior, Anterior, Posterior, Ventral, Dorsal, Supine, Prone, Contralateral Control, Ipsllateral And Contralateral Control, L
Body Planes and Orientation: Transverse Plane, Coronal Plane, Sagittal Plane
Areas Of Health Care Facility: pre-op, OR, PACU, post-op, ICU- intensive care unit:CCU, SICU, PICU, NICU, ER,ED, And ECU, L&D
Abbreviation And Definition: Male, Female, (R) Right, (L) Left, ⬆️ Increased, ⬇️ Decreased
Common On Health Records: VS are made up of the HR, RR, BP and T- I/O input/output- Dx-DDx-Rex-Hx:PMHx:FHx-H&P-CC-HPI-ROS-PE-PCP
Abbreviation Associated with Orders and Administering Medication Po- Per. Os(By Mouth). IV-Intraveneous. SC- Subcutaneous. CVL- Central Venous Line IM- Intramuscular Pr- Per Rectum(Anal). NPO- nil per os( nothing by mouth)
Abbreviations: prn- as needed. QID- four times a day QD-everyday AC-before meals. TID-three times a day. BID-two times a day PC-after meals QHS-at night
Soap is sub what the patient says obj what the tests says analysis sub and obj info and make plan of action for patient.
Types of health records are clinic note, consult note, emergency department note, admission summary, discharge summary, operative report, daily hospital note/progress note, radiology report, pathology report and, prescription.
Common types of terms on health records- subjective, symptom, noncontributory, abrupt
Abbreviations associated with health care-pre-op, OR, PACU, post-op, ICU, ER, ED, ECU. And L&D
Created by: bridgetleyva
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