Med Terms Ch. 2 Word Scramble
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Term | Definition |
chief complaint | the main reason for the patient's visit |
history of illness | the story of the patient's problem |
review of symptoms | description of individual body systems in order to discover any symptoms not directly related to the main problem |
past medical history | other significant past illnesses, like high blood pressure, asthma, or diabetes |
past surgical history | any of the patient's past surgeries |
family history | any significant illness that run in the patient's family |
social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health |
Location of a clinic note | clinic |
location of a consult note | clinic or hospital |
location of an Emergency Department note | emergency department |
location of an admission summary | hospital |
location of a discharge summary | hospital |
location of a progress note | inpatient health care facility |
clinic note | documents a visit |
consult note | provides an expert opinion on a more challenging problem |
discharge summary | describes when and why the patient was admitted; documents a longer stay |
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