Details Title: 02a. The Medical Record Description: Abbreviations Total Flash Cards: 28 Created: 01/27/2009 21:25:09		New Users: To study from this flashcard set, or to create your own your own study flash cards, REGISTER HERE. Existing Users: CLICK HERE. Additional Classics Flashcards
Cards in this set: Term H&P Definition History and Physical - documentation of patient history and physical examination findings Term Hx Definition History - record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits Term subjective information Definition information obtained from the patient including his or her personal perceptions Term CC Definition Chief Complaint Term c/o Definition Complains Of - patient's description of what brought 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 Term HPI (PI) Definition 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) Term Sx Definition Symptom - subjective evidence (from the patient) that indicates an abnormality Term PMH (PH) Definition 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 Term UCHD Definition Usual Childhood Diseases - an abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood Term NKA Definition No Known Allergies Term NKDA Definition No Known Drug Allergies Term FH Definition Family History -state of health of immediate family members Term A&W Definition Alive and Well Term L&W Definition Living and Well Term SH Definition Social History - a record of the patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol Term OH Definition Occupational History - a record of work habits that may involve work-related risks Term ROS (SR) Definition Review Of Systems (Systems Review) 0 a documentation of the patient's response to questions organized by a head-to-toe review of the functions of all body systems Term objective information Definition facts and observations noted Term PE (Px) Definition Physical Examination - documentation of a physical examination of a patient, including notations of positive and negative objective findings Term HEENT Definition Head, Eyes, Ears, Nose, Throat Term NAD Definition No Acute Distress, No Appreciable Disease Term PERRLA Definition Pupils Equal, Round, and Reactive to Light and Accommodation Term WNL Definition Within Normal Limits Term Dx Definition Diagnosis Term IMP Definition Impression Term A Definition Assessment - identification of a disease or condition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures Term R/O Definition Rule Out - used to 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 Term P Definition Plan (also referred to as recommendation or disposition) - outline of the treatment plan designed to remedy the patient's condition, which includes instructions to the patient, orders for medications, diagnostic tests, or therapies