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Medical Terminology
chapter 2 (health care records)
111
Nursing
Undergraduate 2
08/31/2011

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Term
What is the 1st document to be generated when a patient presents for care, and most often is recorded at a new patient visit or as part of a consultation?
Definition
history and physical (H&P)
Term
The 1st portion of the H&P is the history which documents ______ from the patients personal statement about his or her medical history and includes information regarding past injuries, illnesses, operations, defects, and habits.
Definition
subjective information
Term
when handwriting the chief complaint (CC), the abbreviation ______ is used
Definition
c/o (complains of)
Term
Details about the chief complaint (CC) are documented in the ______ or _____, which includes the duration and severity of the complaint
Definition
present illness(PI) or history of present illness (HPI)
Term
What is recorded after the chief complaint (CC)?
Definition
past history (PH) or past medical history (PMH)
Term
what is information is included in the past history(PH) or past medical history(PMH)?
Definition
patients past illnesses(starting with childhood)
surgical operations
physical defects
medications
allergies
Term
What abbreviation is used to record that the patient had all the "usual" or commonly contracted ilnesses during childhood?
Definition
UCHD (usual childhood diseases)
Term
what abbreviation is used to indicate that the patient has had no known allergic reaction to a previously administered drug?
Definition
NKA(no known allergies) or NKDA (no known drug allergies)
Term
The history is complete after documenting the patients answers to questions related ______ or ______
Definition
review of systems (ROS) or systems review (SR)
Term
a head to toe review of the functions of all the body systems
Definition
review of systems (ROS) or systems review (SR)
Term
this review makes it possible to evaluate other symptoms that may not have been mentioned
Definition
review of systems (ROS) or systems review (SR)
Term
After the subjective data are recorded, the provider begins a physical examination(PE) or physical (Px) to obtain _______, facts that can be seen or detected by testing
Definition
objective information
Term
HEENT is used to document the findings of the physical examination. what does HEENT stand for?
Definition
Head, eyes, ears, nose and throat
Term
What does PERRLA mean?
Definition
Pupils Equal, Round, Reactive to Light and Accommodation
Term
what does NAD mean?
Definition
no acute stress
Term
what does WNL mean?
Definition
within normal limits
Term
After the evaluation of all subjective and objective data, the identification of a disease or condition is recorded in the ______, _______, or _______
Definition
impression (IMP)
diagnosis (Dx)
assessment (A)
Term
Often, when one or more diagnoses are in question, a _______ is made using the abbreviation _________.
Definition
differential diagnosis
R/O (rule out)
Term
Final notations include the health care providers ________ also called the ______ or _________. here the provider outlines strategies designed to remedy the patients condition, including instructions to the patient and orders for medications, diagnostic tests, or therapies.
Definition
plan (P), recommendation or disposition
Term
when the patient is to have surgery this report is called?
Definition
preoperative H&P
Term
after the initial H&P is recorded, _____ are used to document the patients continued care
Definition
progress notes
Term
the ______ method of documenting a patients progress is the most common. the letters represent the order in which progress is noted as each complaint or problem is addressed
Definition
SOAP
Term
What does SOAP stand for? and give a definiton of each
Definition
Subjective -that which the patient describes
Objective -observable information (e.g., test results and blood pressure readings)
Assessment-patients progress and evaluation of the plans effectiveness; any newfound problem or diagnosis is also noted here
plan-decision to proceed or alter the plan strategy
Term
A
Definition
assessment
Term
A & W
Definition
alive and well
Term
CC
Definition
chief complaint
Term
c/o
Definition
complains of
Term
Dx
Definition
diagnosis
Term
FH
Definition
family history
Term
H&P
Definition
history and physical
Term
HPI, PI
Definition
history of present illness
present illness
Term
Hx
Definition
history
Term
IMP
Definition
impression
Term
L&W
Definition
living and well
Term
O
Definition
objective information
Term
OH
Definition
occupational history
Term
P
Definition
plan (recommendation, disposition)
Term
PE, Px
Definition
physical examination
Term
PH, PMH
Definition
past history
past medical history
Term
R/O
Definition
rule out
Term
ROS, SR
Definition
review of systems
systems review
Term
S
Definition
subjective information
Term
SH
Definition
social history
Term
Sx
Definition
symptom
Term
UCHD
Definition
usual childhood diseases
Term
WNL
Definition
within normal limits
Term
In a difficult case, a specialist may be called in by the attending physician, and a _______ is filed
Definition
consultation report
Term
if a surgical remedy is indicated, a narrative _______ is required of the primary surgeon. In this report, a detailed account of the operation is given, including the method of incision, technique, instruments used, types of suture, method of closure, and the patients responses during the procedure and at the time of transfer to recovery
Definition
operative report
Term
when a surgery or procedure involves a reasonable risk to the patient, the patient must sign a ______
Definition
informed consent form
Term
_______ note any additional procedures and therapies, including diagnostic tests and pathology reports
Definition
ancillary reports
Term
what are the 2 most common laboratory tests performed?
Definition
CBC or urinalysis(UA)
Term
Radiation used to produce x-rays was found to be ______, a process that changes the electrical charge of atoms and has a possible effect on the body cells
Definition
ionizing
Term
common nonionizing modalities that present no apparent risk include ______ and ______
Definition
magnetic resonance imaging (MRI)
sonography (US)
Term
________is an imaging modality that uses x-rays (ionizing radiation) to produce images of the body's anatomy for the diagnosis of a condition or impairment. an image is created when a small amount of radiation is passed through the body to expose a sensitive film. this image is called _____
Definition
radiography
radiograph
Term
sharp; having intense, often severe symptoms and a short course
Definition
acute
Term
a condition that develops slowly and persists over a period of time
Definition
chronic
Term
mild or noncancerous
Definition
benign
Term
harmful or cancerous
Definition
malignant
Term
gradual deterioration of normal cells and body functions
Definition
degeneration
Term
any disease in which deterioration of the structure or function of tissue occurs
Definition
degenerative disease
Term
determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results)
Definition
diagnosis
Term
study of the cause of a disease
Definition
etiology
Term
increase in the severity of a disease, with aggravation of symptoms
Definition
exacerbation
Term
a period in which symptoms and signs stop or abate
Definition
remission
Term
relating to a fever (elevated temperature)
Definition
febrile
Term
a condition occurring without a clearly identified cause
Definition
idiopathic
Term
limited to a definite area or part
Definition
localized
Term
relating to the whole body rather than to only a part
Definition
systemic
Term
a feeling of uneasiness or discomfort; often the 1st indication of illness
Definition
malaise
Term
significant
Definition
marked
Term
sick; a diseased state
Definition
morbidity
Term
the state of being subject to death
Definition
mortality
Term
foreknowledge; prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease; often noted in one word
Definition
prognosis
Term
pertaining to the advance of a condition as the signs and symptoms increase in severity
Definition
progressive
Term
a process or measure that prevents disease
Definition
prophylaxis
Term
to occur again; describes a return of symptoms and signs after a period of quiescence (rest of inactivity)
Definition
recurrent
Term
a disorder or condition usually resulting from a previous disease or injury
Definition
sequela
Term
a mark; objective evidence of disease that is perceived by the patient and often noted in his or her own words
Definition
symptom
Term
a running together; a combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease.
Definition
syndrome
Term
not involved in bringing on the condition or result
Definition
noncontributory
Term
common; not out of the ordinary or significant
Definition
unremarkable
Term
CCU
Definition
coronary (cardiac) care unit
Term
ECU
Definition
emergency care unit
Term
IP
Definition
inpatient
Term
OP
Definition
out patient
Term
OR
Definition
operating room
Term
PACU
Definition
postanesthetic care unit
Term
PAR
Definition
postanesthetic recovery
Term
RTC
Definition
return to clinic
Term
RTO
Definition
return to office
Term
B (circle around it)
Definition
bilateral
Term
BRP
Definition
bathroom privileges
Term
CP
Definition
chest pain
Term
DC or D/C
Definition
discharge discontinue
Term
ETOH
Definition
ethyl alcohol
Term
L (circle around it)
Definition
left
Term
m (circle around it)
Definition
murmur
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
P
Definition
pulse
Term
T
Definition
temperature
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
y.o
Definition
year old
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