Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
UB Med Term pg 55
The Medical Record
| Abbreviation | Meaning/Explanation |
|---|---|
| H & P | 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 | chief complaint |
| c/o | complains of - patients description of what brought him/her to the doctor/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 complain recording details of duration and severity of the condition (how long the patient has had the complaint and how bad it is) |
| Sx | symptom - subjective evidence (the 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 | usual childhood diseases |
| NKA | no known allergies |
| NKDA | no known drug allergies |
| FH | Family History - state of health of immediate family members - A&W = alive and well, L&W = living and well |
| SH | Social history - recreational interests, hobbies and used of tobacco and drugs |
| OH | Occupational history - work habits that may involve work-related risks |
| ROS (SR) | review of systems (systems review) - documentation of the patients response to questions organized by a head-to-toe review of the function of all body systems |
| objective information | facts and observations noted |
| PE (Px) | Physical Examination |
| HEENT | Head, eyes, ears, nose, throat |
| NAD | no acute distress, no appreciable disease |
| PERRLA | pupils equal, round and reactive to light and accommodation |
| WNL | within normal limits |
| Dx | Diagnosis |
| IMP | Impression |
| A | Assessment - identification of a disease or dondition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests ad diagnostic procedures |
| R/o | Rule Out - used to indicate a differeential 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 aka recommendation or disposition - outline of the treatment plan designeed to remedy the patient's condition, which includes instructions to the patient, orders for medications, diagnostic testsm or therapies |
Created by:
HugsAndKisses
Popular Medical sets