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27 Cards in this Set

  • Front
  • Back
H&P
History and Physical
Hx
History
CC
Chief Complaing
c/o
complains of
HPI (PI)
History of Present Illness (Present Illness)
amplification of the chief complaint recording details of the duration and severity of condition
Sx
symptom
subjective evidence
PMH (PH)
Past Medical History (Past History)
UCHD
usual childhood disease
(e.g. measles, chickenpox, mumps)
NKA
no known allergies
NKDA
no known drug allergies
FH
Family History
state of health of immediate family members
A&W
L&W
Alive & Well
Living & Well
SH
Social History
record of patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol
OH
Occupational History
record of work habits that may involve work-related risks
ROS (SR)
Review Of Systems (Systems Review)
head-to-toe review of function of all body system
PE (Px)
Physical Examination
HEENT
head, eyes, ears, nose, throat
NAD
no acute distress, no appreciable disease
PERRLA
pupils equal, round, and reactive to light and accommodation
WNL
within normal limits
Dx
Diagnosis
IMP
Impression
A
Assessment
identification of disease of condition after evaluation of patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures
R/O
Rule Out
used to indicate differential diagnosis when one or more diagnoses are suspected
P
Plan
(recommendation or disposition)
POMR
Problem Oriented Medical Record (S.O.A.P.)
S.O.A.P.
Subjective
Objective
Assessment
Plan