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| history obtained from patient including his/her personal perceptions |
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| physical facts and observations made by an examiner |
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record of the patient's personal medical history including past injuries, illnesses, operations, defects, and habits.
~ Includes: chief complaint, history of present illness, past history, family history, occupational history and review of systems |
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Chief complaint
-Brief description of why patient is seeking care |
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Complains of
-used in describing complaint |
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Present Ilness or History of Present Illness
-Notation of duration and severity of complaint |
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symptom
-evidence of ilnness that the patient reports |
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Past history or past medical history
-notation of surgeries, injuries, physical defects, medications, allergies |
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Social History
-Recreational interests, hobbies, use of tobacco/drugs |
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Occupational history
-work habits that may involve work related risks |
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Review of Systems or Systems Review
-Questions related to function of the body systems |
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Document of Physical examination of a patient including notations of positive and negative findings
-results of diagnostic testing
-sign: objective eidence of disease |
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| Head, eyes, ears, nose, and throat |
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| pupils equal, round, and reactive to light and accomodation |
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Assessment
-Identification of a disease or condition after evaluation of all subjective and objective information |
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| A differential diagnosis noted when one or more diagnoses are suspect; requires further testing to verify or eliminate each possibilty |
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Plan Recommendation,
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Disposition |
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| Outline of the treatment plan designed to remedy the patient's condition, which includes instructions to the patient and orders for medications, diagnostic tests, or therapies |
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Progress notes made after the initial history and physical is recorded. The letters represent the order in which progress is noted:
S - subjective; that which the patient describes
O - objective; observable information, such as test results, blood pressure readings, etc.
A-Assessment; progress and evaluation of the effectiveness of the plan
p-Plan; decision to proceed or alter strategy |
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History and Physical
Physician's orders
Diagnostic tests/laboratory reports
Nurse's notes
Physician's progress notes
Consultation report
Operative report
Pathology report
Anesthesiologist's report |
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Diagnostic Imaging Modalities
-Ionizing Imaging |
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A process that changes the electrical charge of atoms with a possible effect on body cells; overexposure can have harmful side effects, e.g., cancer
-Radiography (X-Ray)
-Computed Tomography or Computed Axial Tomography
-Nuclear medicine imaging or radionuclide organ imaging |
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Diagnostic Imaging Modalities
-Nonionizing Imaging |
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an imaging process that presents no apparent risk
-magnetic resonance imaging
-sonography |
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| an aftereffect of a disease, condition, or injury |
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| place to recover after surgery |
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| well-developed, well-nourished |
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| Temperature, pulse, respiration, blood pressure (vital signs) |
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every day
*write out "daily" |
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every other day
*spell out every other day |
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left ear, right ear, both ears
left eye, right eye, both eyes
*spell out left ear / right ear etc |
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subcutaneous
*spell out "subcutaneously" or use sub-Q |
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