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| 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? |
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Definition
| history and physical (H&P) |
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| 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. |
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| when handwriting the chief complaint (CC), the abbreviation ______ is used |
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| Details about the chief complaint (CC) are documented in the ______ or _____, which includes the duration and severity of the complaint |
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Definition
| present illness(PI) or history of present illness (HPI) |
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| What is recorded after the chief complaint (CC)? |
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| past history (PH) or past medical history (PMH) |
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| what is information is included in the past history(PH) or past medical history(PMH)? |
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Definition
patients past illnesses(starting with childhood)
surgical operations
physical defects
medications
allergies |
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| What abbreviation is used to record that the patient had all the "usual" or commonly contracted ilnesses during childhood? |
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| UCHD (usual childhood diseases) |
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| what abbreviation is used to indicate that the patient has had no known allergic reaction to a previously administered drug? |
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| NKA(no known allergies) or NKDA (no known drug allergies) |
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| The history is complete after documenting the patients answers to questions related ______ or ______ |
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Definition
| review of systems (ROS) or systems review (SR) |
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| a head to toe review of the functions of all the body systems |
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Definition
| review of systems (ROS) or systems review (SR) |
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| this review makes it possible to evaluate other symptoms that may not have been mentioned |
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Definition
| review of systems (ROS) or systems review (SR) |
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| 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 |
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Definition
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| HEENT is used to document the findings of the physical examination. what does HEENT stand for? |
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| Head, eyes, ears, nose and throat |
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| Pupils Equal, Round, Reactive to Light and Accommodation |
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| After the evaluation of all subjective and objective data, the identification of a disease or condition is recorded in the ______, _______, or _______ |
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impression (IMP)
diagnosis (Dx)
assessment (A) |
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| Often, when one or more diagnoses are in question, a _______ is made using the abbreviation _________. |
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differential diagnosis
R/O (rule out) |
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| 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. |
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| plan (P), recommendation or disposition |
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| when the patient is to have surgery this report is called? |
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| after the initial H&P is recorded, _____ are used to document the patients continued care |
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| 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 |
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| What does SOAP stand for? and give a definiton of each |
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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 |
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history of present illness
present illness |
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| plan (recommendation, disposition) |
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past history
past medical history |
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review of systems
systems review |
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| In a difficult case, a specialist may be called in by the attending physician, and a _______ is filed |
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| 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 |
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| when a surgery or procedure involves a reasonable risk to the patient, the patient must sign a ______ |
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| _______ note any additional procedures and therapies, including diagnostic tests and pathology reports |
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| what are the 2 most common laboratory tests performed? |
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| 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 |
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| common nonionizing modalities that present no apparent risk include ______ and ______ |
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magnetic resonance imaging (MRI)
sonography (US) |
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| ________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 _____ |
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| sharp; having intense, often severe symptoms and a short course |
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| a condition that develops slowly and persists over a period of time |
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| gradual deterioration of normal cells and body functions |
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| any disease in which deterioration of the structure or function of tissue occurs |
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| determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results) |
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| study of the cause of a disease |
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| increase in the severity of a disease, with aggravation of symptoms |
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| a period in which symptoms and signs stop or abate |
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| relating to a fever (elevated temperature) |
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| a condition occurring without a clearly identified cause |
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| limited to a definite area or part |
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| relating to the whole body rather than to only a part |
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| a feeling of uneasiness or discomfort; often the 1st indication of illness |
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| the state of being subject to death |
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| 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 |
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| pertaining to the advance of a condition as the signs and symptoms increase in severity |
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| a process or measure that prevents disease |
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| to occur again; describes a return of symptoms and signs after a period of quiescence (rest of inactivity) |
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| a disorder or condition usually resulting from a previous disease or injury |
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| a mark; objective evidence of disease that is perceived by the patient and often noted in his or her own words |
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| a running together; a combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease. |
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| not involved in bringing on the condition or result |
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| common; not out of the ordinary or significant |
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| coronary (cardiac) care unit |
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| well-developed and well-nourished |
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