Medical Terminology: The Language Of Healthcare Ch. 4

Front 1

H&P

Back 1

History and Physical
Documentation of patient history and physical examination

Front 2

Subjective Information

Back 2

Information obtained from the patient including his or her personal perceptions

Front 3

Hx

Back 3

History
Record of subjective information regarding the patient's personal medical history including past injuries, illnesses, operations, defects, and habits.

Front 4

CC

Back 4

Cheif complaint

Front 5

c/o

Back 5

Complains of
Patient's description of what brought him or her to the doctor or hospital; it is usually brief and is often documented in the patient's own words indicated within quotes (i.e. CC: left lower back pain; patient states, "I feel like I swallowed a stick and it got stuck in my back")

Front 6

PI

Back 6

Present illness

Front 7

HPI

Back 7

History of present illness
Amplification of the cheif complaint recording details of the duration and severity of the condition (i.e. PI: the patient has had lower back pain for the past 2 weeks since slipping on a rug and landing on her left side; the pain worsens after sitting upright for any extended period but gradually subsides after lying in a supine position

Front 8

Sx

Back 8

Symptom
Subjective evidence (from the patient) that indicates an abnormality

Front 9

PH

Back 9

Past history

Front 10

PMH

Back 10

Past medical history
A record of information about the patient's past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies

Front 11

UCHD

Back 11

Usual childhood diseases
An abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood (i.e. measles, mumps, chickenpox)

Front 12

NKA

Back 12

No known allergies

Front 13

NKDA

Back 13

No known drug allergies

Front 14

FH

Back 14

Family history
State of health of immediate family members

Front 15

A&W
L&W

Back 15

Alive and well
Living and well
(i.e. father, age 92, L & W; mother, age 91, died, stroke)

Front 16

SH

Back 16

Social history
A record of the patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol (i.e. SH: plays tennis twice/wk; tobacco-none; alcohol-drinks 1-2 beers per day)

Front 17

OH

Back 17

Occupational History
Record of work habits that may involve work-related risks (i.e. OH: the patient has been employed as a coal mine engineer for the past 16 years)

Front 18

ROS

Back 18

Review of systems

Front 19

SR

Back 19

Systems review
A documentation of the patient's response to questions organized by a head-to-toe review of the function of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned)

Front 20

PE

Back 20

Physical Examination

Front 21

Px

Back 21

Documentation of a physical examination of a patient, including notations of positive and negative object findings

Front 22

HEENT

Back 22

Head, Eyes, Ears, Nose, Throat

Front 23

PERRLA

Back 23

Pupils equal, round, reactive to light and accomodation

Front 24

WNL

Back 24

Within normal limits

Front 25

Dx

Back 25

Diagnosis

Front 26

IMP

Back 26

Impression

Front 27

A

Back 27

Assessment
Identification of a disease or condition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures

Front 28

R/O

Back 28

Rule out
[used to indicate differential diagnosis when two or more possible diagnosis are suspect (note: each possible diagnosis is outlined and then either verified or eliminated after further testing is performed, (i.e. diagnosis: R/O pancreatitis, R/O gastroenterisits) this documentation indicates that either of these two diagnosises is suspected and that further testing is required to eliminate one)]