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Chapter 2
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 |
| Exacerbation | it is getting worse |
| Abrupt | all of the sudden |
| Febrile | to have a fever |
| Afebrile | to not have a fever |
| Malaise | not feeling well |
| Progressive | more and more each day |
| Symptom | something a patient feels |
| Noncontributory | not related to this 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 | it runs in the family |
| Alert | able to answer questions; responsive; interactive |
| Oriented | being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented x 3" |
| Marked | it really stands out |
| Unremarkable | another way of saying normal |
| Auscultation | to listen |
| Percussion | to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
| Palpation | to feel |
| Impression | another way of saying assessment |
| Diagnosis | what the health care professional thinks the patient has |
| Differential Diagnosis | a list of conditions the patient may have based on the symptoms exhibited and the results of the exam |
| Benign | safe |
| Malignant | dangerous; a problem |
| Degeneration | to be getting worse |
| Remission | to get better or improve; most often used when discussing cancer; remission does not mean cure |
| Idiopathic | no known specific cause; it just happens |
| Localized | stay in a certain part of the body |
| Systemic/Generalized | all over the body (or most of it) |
| Prognosis | the chances for getting things better or worse |
| Occult | hidden |
| Lesion | diseased tissue |
| Recurrent | to have again |
| Sequela | a problem resulting from a disease or injury |
| Pending | waiting for |
| Pathogen | the organism that causes the problem |
| Morbidity | the risk for being sick |
| Mortality | the risk of dying |
| Etiology | the cause |
| Disposition | what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed) |
| Discharge | literally to unload; it has two meanings: 1. to send home (to unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (your body unloading fluid) |
| Palliative | treating the symptoms, but not actually getting rid of the cause |
| Observation | watch, keep an eye on |
| Reassurance | to tell the patient that the problem is not serious or dangerous |
| Supportive Care | to treat the symptoms and make the patient feel better |
| Sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery |
| Prophylaxis | preventative treatment |
| Proximal | closer into the center proximal and approximate come from the same word and mean close |
| Distal | further away from the center distal and distant come from the same word and mean far |
| Lateral | out to the side think of a quarterback lateraling a football to a running back |
| Medial | toward the middle like the median of a highway |
| Ventral/Antral/Anterior | the front the word ventral means "stomach" |
| Dorsal/Posterior | the back a dorsal fin on a shark is on its back |
| Cranial | toward the top |
| Caudal | toward the bottom from Latin, for tall |
| Superior | above |
| Inferior | below |
| Prone | laying down on belly |
| Supine | lying down on back |
| Contralateral | opposite side |
| Ipsilateral | same side |
| Unilateral | one side |
| Bilateral | both sides |
| Dorsum | the top of the hand or foot |
| Plantar | the sole of the foot |
| Palmar | the palm of the hand |
| Sagittal | divides the body along a hypothetical plane from right to left sagitta is Latin for arrow; think of this as dividing the body in half, as if someone shot an arrow toward it |
| Coronal | divides the body along a hypothetical plane from front to back -corona is Latin for crown; this plane divides the body in half from the top of the head down like someone putting a crown on the head |
| Transverse | divides the body from the top to the bottom |
| Physician | a skilled health care provider who attended and graduated medical school -there are two types who practice in America: medical doctor (MD) and doctor of osteopathy (DO) |
| Pediatrician | a physician with special training in caring for children |
| Surgeon | a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure |
| Anesthesiologist | a physician with special training in pain sedation and pain control |
| Epidemlogogist | a specialist in the study of the causes and distribution of diseases in populations and the use of this data to enhance public health |
| Physician Assistant (PA) | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
| Nurse Practitioner (NP) | a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician |
| Emergency Medical Technician (EMT) | specially trained in the emergency care of a patient before and/or during transport to medical facility |
| Speech Therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
| Occupational Therapist | specially trained in evaluating and treating problems with performing daily activities at home, school, or work |
| Physical Therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
| Respiratory Therapist | specially trained in treating patients' respiratory issues under the guidance of a health care provider |
| Dietician | specially trained in evaluating the nutritional status of the patient and developing an appropriate diet plan |
| Licensed Practical Nurse (LPN) | trained and certified to provide basic care to a patient |
| Licensed Vocational Nurse (LVN) | trained and certified to provide basic care to a patient |
| Registered Nurse | an advanced level nurse who has completed an associate or bachelor's degree; often assists with patient care planning and patient education |
| Medical Assistant | trained to carry out basic administrative and clinical tasks under the guidance of a health care provider |
| Pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| Medical Laboratory Technician | trained in performing laboratory testing on bodily fluids |
| Phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| Radiologist | a physician specially trained in evaluating images of the body to diagnose illness or injury |
| Radiology Technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| Ultra Sonographer | trained in performing ultrasound imaging on a patient |
| Pharmacist | trained and licensed in preparing and dispensing medicine |
| Pharmacy Technician | trained to assist a pharmacist with pharmacy-related task |
| Patient Service Coordinator | handles the administrative tasks and coordinates patient care |
| Medical Transcriptionist | trained in converting the voice-recorded dictations of health care providers into text format |
| Chief Complaint | the main reason for the patients 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 patients past surgery |
| Family History | any significant illnesses that run in the patients family |
| Social History | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health |
| Clinical Note | documents a visit |
| Consult Note | provides an expert opinion on a more challenging problem |
| Emergency Department Note | documents an emergency department visit |
| Admission Summary | documents the admission of a patient to the hospital |
| Discharge Summary | describes when and why the patient was admitted, documents a longer stay |
| Operative Report | documents a surgery in detail |
| Daily Hospital Note/ Progress Note | documents daily hospital visit |
| Radiology Report | explains reason for image, how image was performed, what was seen on image, radiologists assessment; sometimes a recommendation |
| Pathology Report | provides reasons for test, what was seen on the test, and an assessment |
| Prescription | provides directions for a medication |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ER | emergency room |
| ED | emergency department |
| ICU | intensive care unit |
| PICU | pediatric intensive care unit |
| NICU | neonatal intensive care unit |
| SICU | surgical intensive care |
| PACU | post-anesthesia care unit |
| L&D | labor and delivery |
| OR | operating room |
| Post-op | after surgery |
| Pre-op | before surgery |
| ♂ | male |
| ♀ | female |
| (R) | right |
| (L) | left |
| (B) | bilateral |
| ↑ | increased |
| ↓ | decreased |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output) |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | chief complaint (the main reason of the visit) |
| HPI | history of present illness (the story of the symptoms) |
| ROS | review of systems (anything else not directly related to the chief complaint |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| Pt | patient |
| y/o | years old |
| h/o | history of |
| PCP | primary care provider |
| f/u | follow up |
| SOB | shortness of breath (because of the negative nonmedical use, it has been suggested that SOB should be replaced with SOA= shortness or air |
| HEENT | head, eyes, ears, nose, and throat |
| PEERLA | pupils are equal and reactive to light and accommodation |
| NAD | no acute distress (the patient does not display any intense symptoms |
| CV | cardiovascular |
| RRR | regular rate and rhythm (description of a normal heart on exam) |
| CTA | clear to auscultation (description of normal sounding lungs) |
| WDWN | well developed, well nourished (the patient is growing or has grown appropriately and does not appear to be malnourished) |
| A&O | alert and oriented (the patient can answer questions and is aware of what's going on) |
| WNL | within normal limits |
| NOS | not otherwise specified |
| NEC | not elsewhere classified ( NOS and NEC are catch -all's for diagnosis's that don't quite fit any specific cause ex; rash NOS) |
| PO | per os (by mouth) |
| NPO | nil per os (nothing by mouth) |
| PR | per rectum (anal) |
| IM | intramuscular |
| SC | subcutaneous (under the skin) |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | instructions short for signa, from Latin, for "label" |
Created by:
Gbenson131