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CH. 2

INTRODUCTION TO HEALTH RECORDS

TermDefinition
ANATOMIC POSITION Position where a person is standing facing forward, arms at the side with palms forward.
PMHx Past Medical History
CC Chief Complaint (the main reason for the visit)
HPI History of present illness (the story of the symptoms) -current symptoms
NKDA No Known Drug Allergies
PERRLA Pupils are Equal, Round, and Reactive to Light and Accommodation
NAD No Acute Distress (patient does not display any intense symptoms)
DDx Differential Diagnosis - Dx= diagnosis
AC & PC Before meals & After meals
ad llb as desired
Created by: Kaylaruth711
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