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28 Cards in this Set

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  • Back
H&P
History and Physical
Documentation of patient history and physical examination
Subjective Information
Information obtained from the patient including his or her personal perceptions
Hx
History
Record of subjective information regarding the patient's personal medical history including past injuries, illnesses, operations, defects, and habits.
CC
Cheif complaint
c/o
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")
PI
Present illness
HPI
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
Sx
Symptom
Subjective evidence (from the patient) that indicates an abnormality
PH
Past history
PMH
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
UCHD
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)
NKA
No known allergies
NKDA
No known drug allergies
FH
Family history
State of health of immediate family members
A&W
L&W
Alive and well
Living and well
(i.e. father, age 92, L & W; mother, age 91, died, stroke)
SH
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)
OH
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)
ROS
Review of systems
SR
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)
PE
Physical Examination
Px
Documentation of a physical examination of a patient, including notations of positive and negative object findings
HEENT
Head, Eyes, Ears, Nose, Throat
PERRLA
Pupils equal, round, reactive to light and accomodation
WNL
Within normal limits
Dx
Diagnosis
IMP
Impression
A
Assessment
Identification of a disease or condition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures
R/O
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)]