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UB Med Term pg 55

The Medical Record

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