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Medical Terminology
Sections of a health record
Term | Definition |
---|---|
Chief compliant | the main reason for the patient's visit |
history of present illness | the story of the patient's 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 surgeries |
family history | any significant illnesses that run in the patient's family |
social history | a record of habits like smoking, drinking, drug abuse and sexual practices that can impact health. |