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Chapter 2

terms and definitions

TermDefinition
SOAP Subjective, Objective, Assessment, Plan (the four parts of a health record)
CC Chief Complaint (the main reason for the patient's visit)
HPI History of Present Illness (detailed story of the patient's current symptoms)
PMH Past Medical History (patient's past illnesses, surgeries, and health conditions)
ROS Review of Systems (a head-to-toe checklist of symptoms by body system)
PE Physical Exam (the objective evaluation of the patient's body by the clinician)
Dx Diagnosis (the identification of the nature of an illness or other problem)
Tx Treatment (the medical care given to a patient for an illness or injury)
Prescription Abbreviation: "QID" Four times a day (from the Latin quater in die)
Prescription Abbreviation: "PO" By mouth (from the Latin per os)
Created by: Derriondavis
 

 



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