Chapter 4 Flashcards
1
Q
H & P
A
History and Physical
documentation of patient history and physical exam findings
usually the first document entered into the patient’s hospital record on admission
2
Q
Hx
A
History
record of subjective information regarding the patient’s personal medical history, including past injuries, illnesses, operations, defects, and habits
3
Q
subjective information
A
information obtained from the patient including his or her personal perceptions
4
Q
CC
A
Chief Complaint
5
Q
c/o
A
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”
6
Q
HPI (PI)
A
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
7
Q
Sx
A
symptom subjective evidence (from the patient) that indicates an abnormality
8
Q
PMH (PH)
A
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
9
Q
UCHD
A
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)
10
Q
NKA
A
no known allergies
11
Q
NKDA
A
no known drug allergies
12
Q
FH
A
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
13
Q
SH
A
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
14
Q
OH
A
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
15
Q
ROS (SR)
A
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)
16
Q
PE (Px)
A
Physical Examination
documentation of a physical examination of a patient, including notations of positive and negative objective findings
17
Q
objective information
A
facts and observations noted
18
Q
HEENT
A
head, eyes, ears, nose throat
19
Q
NAD
A
no acute distress, no appreciable disease
20
Q
PERRLA
A
pupils equal, round, and reactive to light and accommodation
21
Q
WNL
A
within normal limits
22
Q
Dx
A
Diagnosis
23
Q
IMP
A
Impression
24
Q
A
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
25
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
26
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
27
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)
28
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
29
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)
30
progress notes
documentation of the progress concerning each problem
| organized using the SOAP format
31
S of SOAP format
subjective
| that which the patient describes
32
O of SOAP format
```
objective
observable information (e.g. test results, BP readings)
```
33
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)
34
P of SOAP format
plan
| decision to proceed or alter the plan strategy
35
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
36
consent form
document signed by the patient or legal guardian giving permission for medical or surgical care
37
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
38
physician's orders
a record of all orders directed by the attending physician
39
diagnostic tests/laboratory reports
records of results of various tests and procedures used in evaluating and treating a patient
40
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)
41
physician's progress notes
physician's daily account of patient's response to treatment, including results of tests, assessment, and future treatment plans
42
ancillary reports
miscellaneous records of procedures or therapies provided during a patient's care (e.g. physical therapy, respiratory therapy)
43
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)
44
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
45
pathology report
report of the findings of a pathologist after the study tissue
46
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
47
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
48
CCU
coronary (cardiac) care unit
49
ECU
emergency care unit
50
ER
emergency room
51
ICU
intensive care unit
52
IP
inpatient (a registered bed patient)
53
OP
outpatient
54
OR
operating room
55
PACU
postanesthetic care unit
56
PAR
post anesthetic recovery
57
post-op/postop
postoperative (after surgery)
58
pre-op/preop
preoperative (before surgery)
59
RTC
return to clinic
60
RTO
return to office
61
BRP
bathroom privileges
62
CP
chest pain
63
DC
| D/C
discharge
discontinue
error-prone abbreviation (preferred use: spell out "discontinue" or "discharge")
64
ETOH
ethyl alcohol
65
circled L
left
66
circled R
right
67
pt
patient
68
RRR
regular rate and rhythm
69
SOB
shortness of breath
70
Tr
treatment
71
Tx
treatment or traction
72
VS
vital signs
73
T
temperature
74
P
pulse
75
R
respiration
76
BP
blood pressure
77
Ht
height
78
Wt
weight
79
WDWN
well-developed and well-nourished
80
y.o.
year old
81
#
number if before the numeral (#2 = number 2)
| pound if after the numeral (150# = 150 pounds)
82
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)
83
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
84
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)
85
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
86
acute
sharp
| having intense, often severe symptoms and a short course
87
chronic
a condition developing slowly and persisting over time
88
benign
mild or noncancerous
89
malignant
harmful or cancerous
90
degeneration
gradual deterioration of normal cells and body functions
91
degenerative disease
any disease in which there is deterioration of structure for function of tissue
92
diagnosis
determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results)
93
etiology
cause of a disease
94
exacerbation
increase in severity of a disease with aggravation of symptoms
95
remission
a period in which symptoms and signs stop or abate
96
febrile
relating to a fever (elevated temperature)
97
gross
large
| visible to the naked eye
98
idiopathic
a condition occurring without a clearly identified cause
99
localized
limited to a definite area or part
100
systemic
relating to the whole body rather than only a part
101
malaise
a feeling of unwellness
| often the first indication of illness
102
marked
significant
103
equivocal
vague, questionable
104
morbidity
sick
| a state of disease
105
morbidity rate
the number of cases of a disease in a given year
| the ratio of sick to well individuals in a given population
106
mortality
the state of being subject to death
107
mortality rate
death rate
| ratio of total number of deaths to total number in a given population
108
prognosis
foreknowledge
prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease
109
progressive
the advance of a condition as signs and symptoms increase in severity
110
prophylaxis
a process or measure that prevents disease
111
recurrent
to occur again
| describes a return of symptoms and signs after a period of quiescence (rest or inactivity)
112
sequela
a disorder or condition after, and usually resulting from, a previous disease or injury
113
sign
a mark
| objective evidence of disease that can be seen or verified by an examiner
114
symptom
occurrence
| subjective evidence of disease that is perceived by the patient and is often noted in his or her own words
115
syndrome
a running together
combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease (e.g. menopausal syndrome)
116
noncontributory
not involved in bringing on the condition or result
117
unremarkable
not significant or worthy of noting
118
cc
cubic centimeter
1 cc = 1 mL
error-prone abbreviation
119
cm
centimeter
| 2.5 cm = 1 inch
120
g
| gm
gram
121
kg
kilogram
1000 g
2.2 pounds
122
L
liter
123
mg
milligram
| 0.001 g
124
mL
milliliter
| 0.001 L
125
mm
millimeter
| 0.001 m
126
cu mm
cubic millimeter
127
fl oz
fluid ounce
128
gr
grain
129
gt
drop
130
gtt
drops
131
dr
dram
| 1/8 ounce
132
oz
ounce
133
```
lb
#
```
pound
| 16 ounces
134
qt
quart
| 32 ounces
135
tablet (tab)
| capsule (cap)
forms: oral (per os; p.o), sublingual (SL), buccal
| route of administration: by mouth, under the tongue in the cheek
136
suppository
forms: vaginal (per vagina; PV), rectal (per rectum; PR)
| route of administration: inserted in vagina, inserted in rectum
137
fluid
forms: inhalation
| route of administration: inhaled through nose or mouth
138
parenteral
forms: by injection (intradermal - ID, intramuscular - IM, intravenous - IV, subcutaneous - Sub-Q)
route of administration: within the skin, within the muscle, within the vein, under the skin
139
cream, lotion, ointment
forms: topical
| route of administration: applied to the surface of the skin
140
transdermal
route of administration: absorption of a drug through unbroken skin
141
implant
route of administration: a drug reservoir imbedded in the body to provide continual infusion of a medication
142
prescription
written direction by a physician for dispensing or administering a medication to a patient
143
chemical name of a drug
assigned to a drug in the laboratory at the time it is invented
144
generic name of a drug
the official, nonproprietary name given a drug
145
trade or brand name of a drug
the manufacturer's name for a drug
146
q.d.
error-prone abbreviation (preferred use: spell out daily)
| every day
147
q.o.d.
error-prone abbreviation (preferred use: spell out every other day)
every other day
148
AS
AD
AU
left ear
right ear
both ears
error-prone abbreviation (preferred use: spell out)
149
OS
OD
OU
left eye
right eye
both eyes
error-prone abbreviation (preferred use: spell out)
150
SC
| SQ
error-prone abbreviation (preferred use: spell out "subcutaneously" or use Sub-Q)
subcutaneous
151
>
greater than
less than
error-prone abbreviation (preferred use: spell out)
152
ā
before
| Latin: ante
153
a.c.
before meals
| Latin: ante cibum
154
a.m.
before noon
| Latin: ante meridiem
155
b.i.d.
twice a day
| Latin: bis in die
156
d
day
157
h
hour
| Latin: hora
158
h.s.
at hour of sleep (bedtime)
Latin: hora somni
error-prone abbreviation
159
noc.
night
| Latin: noctis
160
p
after
| Latin: post
161
p.c.
after meals
| Latin: post cibum
162
p.m.
after noon
| Latin: post meridiem
163
p.r.n.
as needed
| Latin: pro re nata
164
q
every
| Latin: quaque
165
q h
every hour
| Latin: quaque hora
166
q 2 h
every 2 hours
167
q.i.d.
four times a day
| Latin: quater in die
168
STAT
immediately
| Latin: statim
169
t.i.d.
three times a day
| Latin: ter in die
170
wk
week
171
yr
year
172
ad lib.
as desired
| Latin: ad libitum
173
amt
amount
174
aq
water
| Latin: aqua
175
C
celsius
| centigrade
176
ć
with
| Latin: cum
177
F
Farenheit
178
NPO
nothing by mouth
| Latin: non per os
179
circled m
murmur
180
circled B
bilateral
181
per
by or through
182
p.o.
by mouth
| Latin: per os
183
PR
through rectum
| Latin: per rectum
184
PV
through vagina
| Latin: per vagina
185
q.n.s.
quantity not sufficient
186
q.s.
quantity sufficient
187
Rx
recipe
| prescription
188
Sig:
label
instruction to the patient
Latin: signa
189
ś
without
| Latin: sine
190
śś
one-half
Latin: semis
error-prone abbreviation
191
w.a.
while awake
192
x
times (e.g. x 6 = six times)
| for (e.g. x 2 d = for 2 days)
193
1:00 a.m.
0100
194
2:00 a.m.
0200
195
2:15 a.m.
0215
196
3:00 a.m.
0300
197
4:00 a.m.
0400
198
5:00 a.m.
0500
199
6:00 a.m.
0600
200
7:00 a.m.
0700
201
8:00 a.m.
0800
202
9:00 a.m.
0900
203
10:00 a.m.
1000
204
11:00 a.m.
1100
205
12:00 p.m.
| noon
1200
206
1:00 p.m.
1300
207
2:00 p.m.
1400
208
3:00 p.m.
1500
209
4:00 p.m.
1600
210
5:00 p.m.
1700
211
6:00 p.m.
1800
212
7:00 p.m.
1900
213
8:00 p.m.
2000
214
9:00 p.m.
2100
215
10:00 p.m.
2200
216
11:00 p.m.
2300
217
12:00 a.m.
| midnight
2400
