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24 Cards in this Set
- Front
- Back
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History and Physical (H&P)
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documentation of patient history and physical examination findings
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History (Hx)
Part of H&P Subjective |
record of subjective information regarding the patient's personal medical history
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Subjective information
Part of H&P |
information obtained from the patient including his or her personal perceptions
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Chief Complaint (CC)
Complains of (c/o) Part of H&P; subjective |
C/o= patient's description of what caused them to seek care; brief, use direct quotes also
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History of Present Illness (HPI)
Subjective |
amplification of chief complaint recording details of duration and severity of condition
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Symptom (Sx)
Subjective |
subjective evidence that indicates an abnormality
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Past Medical History (PMH)
Subjective |
record of info about patient's past illnesses starting with childhood; surgeries, injuries, medications, allergies
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Usual Childhood Diseases (UCHD)
Part of PMH; subjective |
used to notee that patient had commonly contracted illnesses during childhood
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NKA
subjective |
no known allergies; part of PMH
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NKDA
subjective |
no known drug allergies; part of PMH
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Family History (FH)
subjective |
state of health of immediate family members; A&W alive and well- L&W living and well
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Social History (SH)
subjective |
record of patient's recreational interests, hobbies, use of tobacco and drugs
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Occupational History (OH)
subjective |
record of work habits that may involve work-related risks
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Review of Systems (ROS) or (SR)
subjective |
documentation of patient's response to questions organized in head-to-toe review of function of all body systems
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Physical Examination (PE/Px)
Objective |
documentation of physical exam of a patient, including notations of positive and negative objective findings
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Head, Eyes, Ears, Nose, Throat (HEENT)
Part of PE Objective |
exam of HEENT
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No acute distress/no appreciable disease (NAD)
Part of PE Objective |
no description needed
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Pupils equal, round, and reactive to light and accommodation (PERRLA)
Part of PE, objective |
self-explanatory
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Within normal limits (WNL)
Objective |
used in describing findings of PE
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Diagnosis (Dx)
Objective |
obvious
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Impression (IMP)
Objective |
obvious
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Assessment (A)
Objective |
identification of a disease or condition after eval of Hx, sx, signs, results of lab tests and diagnostic procedures
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Rule Out (R/O)
Objective |
used to indicate a differential Dx when one or more Dx are suspect; each poss. Dx is outlined & verified or elim after further testing
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Plan (P)
Objective |
also reoutline of treatment plan designed to remedy patient's condition- includes instructions to pt, orders for meds, Dx tests, therapies
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