Health Records
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| General assessment terms: impression, diagnosis, differential diagnosis, etiology vs. idiopathic, benign vs. malignant, remission
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| General assessment terms ( cont.): morbidity, mortality, prognosis, localized vs. systemic / generalized, pathogen, lesion, sequelae
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| General plan terms: disposition, observation, reassurance, supportive care, palliative
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| Common terms on health records- Body Planes and Orientation
Distal, Proximal, Medial, Lateral, Midline, Right, Left, Superior, Inferior, Anterior, Posterior, Ventral, Dorsal, Supine, Prone, Contralateral Control, Ipsllateral And Contralateral Control, L
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| Body Planes and Orientation: Transverse Plane, Coronal Plane, Sagittal Plane
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| Areas Of Health Care Facility: pre-op, OR, PACU, post-op, ICU- intensive care unit:CCU, SICU, PICU, NICU, ER,ED, And ECU, L&D
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| Abbreviation And Definition: Male, Female, (R) Right, (L) Left, ⬆️ Increased, ⬇️ Decreased
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| Common On Health Records: VS are made up of the HR, RR, BP and T- I/O input/output- Dx-DDx-Rex-Hx:PMHx:FHx-H&P-CC-HPI-ROS-PE-PCP
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| Abbreviation Associated with Orders and Administering Medication
Po- Per. Os(By Mouth). IV-Intraveneous. SC- Subcutaneous. CVL- Central Venous Line IM- Intramuscular Pr- Per Rectum(Anal). NPO- nil per os( nothing by mouth)
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| Abbreviations: prn- as needed. QID- four times a day QD-everyday AC-before meals. TID-three times a day. BID-two times a day PC-after meals QHS-at night
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| Soap is sub what the patient says obj what the tests says analysis sub and obj info and make plan of action for patient.
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| Types of health records are clinic note, consult note, emergency department note, admission summary, discharge summary, operative report, daily hospital note/progress note, radiology report, pathology report and, prescription.
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| Common types of terms on health records- subjective, symptom, noncontributory, abrupt
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| Abbreviations associated with health care-pre-op, OR, PACU, post-op, ICU, ER, ED, ECU. And L&D
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