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30 Cards in this Set
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- Back
- 3rd side (hint)
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H & P
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History and Physical
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documentation of patient history & physical examination findings
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subjective information
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history obtained from the patient including his/her personal perception
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objective information
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physical facts & observations made by an examiner
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Hx
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History
what is it? |
record of 'subjective information' regarding patient's personal medical history, including past injuries, illnesses, operations, defects & habits
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Hx
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History
what does it include? |
chief complaint, history of present illness, past history, family history, social history, occupational history and review of symptoms.
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CC
another term for it? |
Chief Complaint
& c/o c/o stands for? |
complains of brief description of why patient is seeking care (brief&usually documented in patient's own words indicated within quotes)
--------------------------------- c/o = complains of |
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c/o
another term for it? |
complains of
& CC CC stands for? |
complains of brief description of why patient is seeking care (brief&usually documented in patient's own words indicated within quotes)
--------------------------------- CC = Chief Complaint |
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PI
another term for it? |
Present Illness
& HPI HPI stands for? |
notation of duration & severity of (chief) complaint.
how bad is it? how long have they had it? |
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Sx
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symptom
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subjective evidence (from the patient) that indicates an abnormality
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PH
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Past History
another term for it? |
a record of information about the patient's past illnesses starting with childhood, including surgeried, injuries, physical defects, medications & allergies.
-------------------------------- PMH = Past Medical History PH = Past History |
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PMH
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Past Medical History
another term for it? |
a record of information about the patient's past illnesses starting with childhood, including surgeried, injuries, physical defects, medications & allergies.
-------------------------------- PH = Past History PMH = Past Medical History |
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UCHD
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usual childhood diseases
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an abbreviation used to note that the patient had the 'usual' or commonly contracted illnesses during childhood (e.g: measles, chickenpox, mumps)
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NKA
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no known allergies
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NKDA
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no known drug allergies
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FH
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Family History
& A & W stands for? L & W stands for? |
state of health of immediate family members
---------------------------------- A & W = alive and well L & W = living and well |
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SH
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Social History
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a record of patient's recreational interests, hobbies and use of tobacco/drugs/alcohols.
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OH
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Occupational History
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a record of work habbits that may involve work-related risks.
(e.g: the patient has been employed as a heavy equipment operator for the past 6 years) |
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ROS
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Review of Symptoms
another term for it? |
a documentation of the patient's response to head-to-toe review of the functions of all body systems (note: this allows evaluation of other symptoms that may not have been mentioned)
------------------------------------------ SR = Symptoms Review ROS = Review of Symptoms |
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SR
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Symptoms Review
another term for it? |
a documentation of the patient's response to head-to-toe review of the functions of all body systems (note: this allows evaluation of other symptoms that may not have been mentioned)
------------------------------------------ ROS = Review of Symptoms SR = Symptoms Review |
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PE
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Physical Examination
another term for it? |
document of physical examination of a patient including notations of positive & negative findings.
(includes result of diagnostic testings) ------------------------------------- Px = Physical examination PE = Physical examination |
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Px
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Physical examination
another term for it? |
document of physical examination of a patient including notations of positive & negative findings.
(includes result of diagnostic testings) ------------------------------------- PE = Physical examination Px = Physical examination |
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HEENT
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head, eyes, ears, nose, throat
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PERRLA
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pupils equal, round & reactive to light and accomodation
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NAD
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no acute distress, no appreciable disease
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WNL
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within normal limits
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IMP
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Impression
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Dx
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Diagnosis
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A
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Assessment
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identification of a disease or condition after evaluation of all subjective & objective information
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R/O
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Rule Out
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a differential diagnosis noted when one or more diagnoses are suspect - requires further testing to verify or eliminate each possibility
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P
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Plan
also to referred to as? |
outline of the treatment plan designed to remedy the patient's condition, which includes instructions to the patient, orders for medications, diagnostic tests, or therapies
------------------------------------ P = Plan (also referred to as: recommendation or disposition) |
