Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
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 |
