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Med Term Chapt 4
Vocabulary
| Question | Answer |
|---|---|
| H | History and Physical Documentation of patient history and physical examination findings |
| Hx | History Record of subjective information regarding the patient’s personal medical history, including past injuries, illnesses, operations, defects and habits |
| subjective information | Information obtained from the patient including his or her personal perceptions |
| CC | cheif complaint |
| c/o | Complains of Patients description of what brings him or her to the doctor or hospital; it is usually brief and is often documented in the patient’s own words, indicated with quotes |
| HPI (PI) | History of present illness (present illness) Amplification of the chief complaint recording details of the duration and severity of the condition (how long the patient has had the complaint and how bad it is) |
| Sx | Symptom Subjective evidence (from the patient) that indicates an abnormality |
| PMH (PH) | Past Medical History (Past History) A record of information about the patient’s past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications and allergies |
| UCHD | Unusual childhood diseases |
| NKA | no known allergies |
| NKDA | no known drug allergies |
| FH | Family History State of health of immediate family members |
| A | alive and well |
| L | living and well |
| SH | Social History A record of the patients recreational interests, hobbies, and use of tobacco and drugs, including alcohol |
| OH | Occupational History A record of work habits that may involve work related risks |
| ROS (SR) | Review of Systems (System Review) A documentation of the patient’s response to questions organized by a head-to-toe review of the function of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned) |
| Objective information | facts and observations noted |
| PE (Px) | Physical Examination Documentation of a physical examination of a patient, including notations of positive and negative objective findings |
| HEENT | Head, ees, ears, nose, throat |
| NAD | no acute distress, no appreciable disease |
| PERRLA | Pupils equal, round, and reactive to light and accommodation |
| Dx | Diagnosis |
| IMP | Impression |
| A | Assessment Identification of a disease or condition after evaluation of the patient’s history, symptoms, signs, and results of laboratory tests and diagnostic procedures |
| R/O | Rule Out Used indicate a differential diagnosis when one or more diagnoses are suspect; each possible diagnosis is outlined and either verified or eliminated after further testing is performed |
| P | Plan (also referred to as recommendation or disposition) Outline of the treatment plan designed to remedy toe patients’ condition, which includes instructions to the patient, orders for medications, diagnostic tests or therapies. |
| POMR | a method of record keeping that is a highly organized approach that encourages a precise method of documenting the logical thought processes of healthcare professionals. |
| What are the 4 sections of a POMR? | data base, problem list, initial plan, progress notes |
| What does SOAP stand for? | subjective, objective, assessment, plan |
| History and physical | Documentation of the patient’s medical recent medical history and results of a physical examination required before hospital admission (e.g. before admission for surgery) |
| consent form | Document signed by the patient or legal guardian giving permission for medical or surgical care |
| Physician's orders | A record of all orders directed by the attending physician |
| Diagnostic tests/laboratory reports | Records of various tests and procedures used in evaluating and treating a patient |
| Nurse’s notes | Documentation of patient care by the nursing staff (note: flow charts and graphs are often used to display recordings of vital signs and other monitored procedures) |
| Physician’s progress notes | Physician’s daily account of patient’s response to treatment, including the results of tests, assessment, and future treatment plans |
| Ancillary reports | Miscellaneous records of procedures or therapies provided during a patient’s care (e.g. physical therapy, respiratory therapy) |
| Consultation report | Report filed by a specialist asked by the attending physician to evaluate a difficult case; note: a patient may also see another physician in consultation as an outpatient (in a medical office or clinic) |
| Operative report (op report) | Surgeon’s detailed account of the operation including the method of incision, technique, instruments used, types of sutures, method of closure and the patient’s responses during the procedure and at he time of transfer to recovery |
| Pathology report | Report of the findings of a pathologist after the study of tissue |
| Anesthesiologist’s report | Anesthesiologist’s or anesthetist’s report of the details of anesthesia during surgery, including the drugs used, dose and time given and records indicating monitoring of the patient’s vital signs throughout the procedure |
| Discharge summary, clinical resume, clinical summary, discharge abstract | Four terms that describe an outline summary of the patient’s hospital care, including the date of admission, diagnosis, course of treatment, final diagnosis, and date of discharge |
| CCU | Coronary (cardiac) care unit |
| ECU | Emergency care unit |
| ER | Emergency room |
| ICU | Intensive care unit |
| IP | Inpatient (a registered bed patient) |
| OP | Out patient |
| OR | Operating room |
| PACU | Post anesthetic care unit |
| PAR | Post anesthetic recovery |
| Post-op/postop | Postoperative (after surgery) |
| Pre-op/preop | Preoperative (before surgery) |
| RTC | Return to clinic |
| RTO | Return to office |
| BRP | Bathroom privileges |
| CP | Chest pain |
| DC, D/C | Discharge, discontinue * prone to error* |
| ETOH | Ethyl alcohol |
| (L) | (circled) left |
| (R) | (circled) right |
| pt | Patient |
| RRR | Regular rate and rhythm |
| SOB | Shortness of breath |
| Tr | Treatment |
| Tx | Treatment or traction |
| VS | Vital signs |
| T | Temperature |
| P | Pulse |
| R | Respiration |
| BP | Blood pressure |
| Ht | Height |
| Wt | Weight |
| WDWN | Well developed and well nourished |
| y.o. | Year old |
| # | Number or pound: if before a number it means number (#2= number two) if after a number it means pounds (160#= 160 pounds) |
| ♀ | Female |
| ♂ | Male |
| * | Degree or hour |
| ↑ | Increased |
| ↓ | Decreased |
| Ѳ | None or negative |
| Acute | Sharp; having intense, often severe symptoms and a short course |
| Chronic | A condition developing slowly and persisting over time |
| Benign | Mild on noncancerous |
| Malignant | Harmful or cancerous |
| Degeneration | Gradual deterioration of normal cells and body functions |
| Degenerative disease | Any disease in which there is deterioration of structure or function of tissue |
| Diagnosis | Determination of the presence of a disease based on an evaluation of symptoms, signs and test finds (dia= through, gnosis=knowing) |
| Etiology | Cause of a disease (etio=cause) |
| Exacerbation | Increase in severity of a disease with aggravation of symptoms (ex=out, acerbo= harsh) |
| Remission | A period in which symptoms and signs stop or abate |
| Febrile | Relating to a fever (elevated temperature) |
| Gross | Large, visible to the naked eye |
| Idiopathic | A condition occurring without a clearly identified cause (idio=one’s own) |
| Localized | Limited to a definite area or part |
| Systemic | Relating to the whole body rather than one part |
| Malaise | A feeling of unwellness, often the first indication of illness |
| Marked | Significant |
| Equivocal | Vague, questionable |
| Morbidity | Sick, a state of disease |
| Morbidity rate | The number of cases of a disease in a given year. The ratio of sick to well individuals in a given population |
| Mortality | The state of being subject to death |
| Mortality rate | Death rate, ratio of total number of deaths to total number in a given population |
| Prognosis | Foreknowledge; prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease |
| Progressive | The advance of a condition as signs and symptoms increase in severity |
| Prophylaxis | A process or measure that prevents disease |
| Recurrent | To occur again, describes a return of symptoms and signs after a period of quiescence (rest or inactivity) |
| Sequela | A disorder or condition after and usually resulting from, a previous injury or disease |
| Sign | A mark; objective evidence of disease that can be seen or verified by an examiner |
| Symptom | Occurrence; subjective evidence of disease that is perceived by the patient and often noted in his or her own words |
| Syndrome | A running together; combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease, e.g. menopausal syndrome |
| Noncontributory | Not involved in bringing on the condition or result |
| Unremarkable | Not significant or worthy of noting |
| cc | Cubic centimeter (1cc=1 mL) |
| cm | Centimeter (2.5 cm= 1 inch) |
| g/gm | Gram |
| kg | Kilogram (1000 g, 2.2 lbs) |
| L | Liter |
| mg | Milligram (.001 g) |
| ml, mL | Milliliter (.001 L) |
| mm | Millimeter (.001 m) |
| cu mm | Cubic millimeter |
| fl oz | Fluid ounce |
| gr | Grain |
| gt | Drop (L. gutta=drop) |
| gtt | Drops |
| dr | Dram (1/8 ounce) |
| oz | Ounce |
| lb or # | Pound (16 ounces) |
| qt | Quart |
| Tablet (tab) | Oral [per os (p.o)]:By mouth |
| Capsule (cap) | Sublingual (SL):Under the tongue or Buccal:In the cheek |
| Suppository (suppos) | Vaginal [per vagina (PV)]:Inserted in vagina or Rectal [per rectum (PR)]:Inserted in rectum |
| fluid | Inhalation:Inhaled through the nose or mouth, e.g. aerosol (spray) or neblizer (device used to produce a fine mist or spray, often in a metered dose |
| Parenteral | By injection-Intradermal (ID):Within the skin, Intramuscular (IM):Within the muscle, Intravenous (IV):Within the vein, Subcutaneous (Sub-Q): Under the skin |
| Cream, lotion, ointment | Topical:Applied to the surface of the skin |
| Other delivery systems | Trans dermal:Absorption of a drug through unbroken skin ,Implant: A drug reservoir imbedded in the body to provide continual infusion of a medication |
Created by:
Kachmiel
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