Chapter 4 Flashcards
H & P
History and Physical
documentation of patient history and physical exam findings
usually the first document entered into the patient’s hospital record on admission
Hx
History
record of subjective information regarding the patient’s personal medical history, including past injuries, illnesses, operations, defects, and habits
subjective information
information obtained from the patient including his or her personal perceptions
CC
Chief 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
Example: left lower back pain; patient states, “I feel like I swallowed a stick and it got stuck in my back”
HPI (PI)
History of Present Illness (Present Illness)
amplification of the chief complaint recording details of the duration and severity of the condition (how long the patient has had the complaint and how bad is it)
Example: the patient has had left lower back pain for the past two 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
PMH (PH)
Past Medical History (Past 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 (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 (alive and well) or L & W (living and well)
Example: 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
Example: plays tennis twice/week; tobacco - none; alcohol - drinks 1-2 beers/day
OH
Occupational History
a record of work habits that may involve work-related risks
Example: the patient has been employed as a heavy equipment operator for the past 6 years
ROS (SR)
Review of Systems (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 (Px)
Physical Examination
documentation of a physical examination of a patient, including notations of positive and negative objective findings
objective information
facts and observations noted
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 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 a differential diagnosis when one or more diagnoses are suspect; each possible diagnosis is outlined and either verified or eliminated after further testing is performed
Example: R/O pancreatitis
R/O gastroenteritis
this indicates that either of these two diagnoses is suspected and further testing is required to verify
P
Plan (also referred to as recommendation or disposition)
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
problem-oriented medical record (POMR)
method of record keeping introduced in the 1960s
highly organized approach that encourages a precise method of documenting the logical thought processes of health care professionals
data are organized so that information can be accessed readily at a glance, with a focus on the patient’s health problem(s)
problem list
directory of the patient’s problems; each problem is listed and often assigned a number
problems include a specific diagnosis, a sign or symptom, an abnormal diagnostic test result, and any other problem that may influence health or well-being
initial plan
the strategy employed to resolve each problem
includes 3 subdivisions: diagnostic plan (orders are given for specific diagnostic testing to confirm suspicions), therapeutic plan (goals for therapy), and patient education (instructions communicated to the patient)
progress notes
documentation of the progress concerning each problem
organized using the SOAP format
S of SOAP format
subjective
that which the patient describes
O of SOAP format
objective observable information (e.g. test results, BP readings)
A of SOAP format
assessment
patient’s progress and evaluation of the plan’s effectiveness (note: any new problem identified is added to the problem list, and a separate plan for its treatment is recorded)
P of SOAP format
plan
decision to proceed or alter the plan strategy
hospital records
includes history and physical, consent form, informed consent, physician’s orders, diagnostic tests/laboratory reports, nurse’s notes, physician’s progress notes, ancillary reports, consultation report, operative report (op report), pathology report, anesthesiologist’s report, discharge summary/clinical resume/clinical summary/discharge abstract
consent form
document signed by the patient or legal guardian giving permission for medical or surgical care
informed consent
consent of a patient after being informed of the risks and benefits of a procedure and alternatives - often required by law when a reasonable risk is involved
physician’s orders
a record of all orders directed by the attending physician
diagnostic tests/laboratory reports
records of results of various tests and procedures used in evaluating and treating a patient
nurse’s notes
documentation of patient care by the nursing staff (note: flow sheets and graphs are often used to display recordings of vital signs and other monitored procedures)
physician’s progress notes
physician’s daily account of patient’s response to treatment, including results of tests, assessment, and future treatment plans
ancillary reports
miscellaneous records of procedures or therapies provided during a patient’s care (e.g. physical therapy, respiratory therapy)
consultation report
report filed by a specialist asked by the attending physician to evaluate a difficult cases (note: a patient may also see another physician in consultation as an outpatient)
operative report (op report)
surgeon’s detailed account of the operation including the method of incision, technique, instruments used, types of sutures, method of closure, and the patient’s responses during the procedure and at the time of transfer to recovery
pathology report
report of the findings of a pathologist after the study tissue
anesthesiologist’s report
anesthesiologist’s or anesthetist’s report of the details of anesthesia during surgery, including the drugs used, dose and time given, and records indicating monitoring of the patient’s vital status throughout the procedure
discharge summary
clinical resume
clinical summary
discharge abstract
four terms that describe an outline summary of the patient’s hospital care, including date of admission, diagnosis, course of treatment, final diagnosis, and date of discharge
CCU
coronary (cardiac) care unit
ECU
emergency care unit
ER
emergency room
ICU
intensive care unit
IP
inpatient (a registered bed patient)
OP
outpatient
OR
operating room
PACU
postanesthetic care unit
PAR
post anesthetic recovery
post-op/postop
postoperative (after surgery)
pre-op/preop
preoperative (before surgery)
RTC
return to clinic
RTO
return to office
BRP
bathroom privileges
CP
chest pain
DC
D/C
discharge
discontinue
error-prone abbreviation (preferred use: spell out “discontinue” or “discharge”)
ETOH
ethyl alcohol
circled L
left
circled R
right
pt
patient
RRR
regular rate and rhythm
SOB
shortness of breath
Tr
treatment
Tx
treatment or traction
VS
vital signs
T
temperature
P
pulse
R
respiration
BP
blood pressure
Ht
height
Wt
weight
WDWN
well-developed and well-nourished
y.o.
year old
#
number if before the numeral (#2 = number 2)
pound if after the numeral (150# = 150 pounds)
2 most common laboratory tests performed as part of a general health inquiry or to rule out a particular condition
complete blood count (CBC) and urinalysis (UA)
ionizing diagnostic imaging modalities
changes the electrical charge of atoms with a possible effect on body cells
overexposure to ionizing radiation can have harmful side effects
common modalities include radiography (x-ray), computed tomography (CT), and nuclear medicine imaging or radio nucleotide organ imaging
nonionizing diagnostic imaging modalities
magnetic resonance imaging (MRI; particularly useful in examining soft tissues, joints, and the brain and spinal cord) and sonography (diagnostic ultrasound)
use of contrast
some imaging procedures require the internal administration of a contrast medium to enhance the visualization of anatomical structures
contrast media are diverse and include barium, iodinated compounds, gasses (air, carbon dioxide), and other chemicals known to increase visual clarity
can be injected, swallowed, or introduced through an enema or catheter depending on the medium
acute
sharp
having intense, often severe symptoms and a short course
