Details Title: Ch 4 - Medical Record Description: Terms Total Flash Cards: 57 Created: 09/03/2009 09:40:27		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 Term Hx Definition History Term subjective information Definition information obtained from the patients personal perspective Term CC Definition Chief Complain Term c/o Definition complains of Term HPI Definition History of Present Illness Term Sx Definition Symptom Term PMH Definition Past Medical History Term UCHD Definition usual childhood diseases Term NKA Definition no known allergies Term NKDA Definition no known drug allergies Term FH Definition Family History Term SH Definition Social History Term OH Definition Occupational History Term ROS Definition Review of Systems Term objective information Definition facts and observations made Term PE Definition Physical Examination Term HEENT Definition head, eyes, ears, nose, throat Term NAD Definition no acute distress, no appreciable disease Term WNL Definition within normal limits Term Dx Definition Diagnosis Term IMP Definition Impression Term A Definition Assessment Term R/O Definition Rule Out Term P Definition Plan (recommendation or disposition) Term CCU Definition coronary care unit Term ECU Definition emergency care unit Term ER Definition emergency room Term ICU Definition intensive care unit Term IP Definition inpatient Term OP Definition outpatient Term OR Definition operating room Term PACU Definition post-anesthetic care unit Term postop Definition postoperative Term preop Definition preoperative Term RTC Definition return to clinic Term RTO Definition return to office Term BRP Definition bathroom privileges Term CP Definition chest pain Term DC, D/C Definition discharge Term ETOH Definition ethyl alcohol Term (L) Definition left Term (R) Definition right Term pt Definition patient Term RRR Definition regular rate and rhythm Term SOB Definition shortness of breath Term Tr Definition treatment Term Tx Definition treatment or traction Term VS Definition vital signs Term T Definition temperature Term P Definition pulse Term R Definition respiration Term BP Definition blood pressure Term Ht Definition Height Term Wt Definition Weight Term WDWN Definition well-developed and well-nourished Term y.o. Definition year old