Medical Record & Health History Flashcards
Chapter 1 (127 cards)
1
Q
Medical Record
A
a written record of important information regarding a patient, their care, and progress of their condition.
2
Q
HIPAA
A
Health Insurance Portability and Accountability Act
3
Q
What is HIPPA?
A
4
Q
Symptom
A
a symptom is any change in the body or its functioning that indicates the presence of disease.
5
Q
Subjective symptom
A
6
Q
Objective symptom
A
7
Q
Charting
A
the process of making written entries about a patient in the medical records.
8
Q
Patient
A
an individual receiving medical care.
9
Q
Review of Systems (ROS)
A
10
Q
Diagnosis
A
the scientific method of determining and identifying a patient’s condition.
11
Q
Prognosis
A
the probable course and outcome of a patient’s condition and the patient’s prospects for recovery.
an assumption of what the symptoms are representing.
12
Q
Chief Complaint (CC)
A
13
Q
New patient vs. Established patient
A
14
Q
Medical Office Administrative Docs
A
15
Q
Dysuria
A
difficult or painful urination.
16
Q
Polyuria
A
increased output of urine.
17
Q
admin
A
administer (med. abbreviation)
18
Q
amt
A
amount (med. abbreviation)
19
Q
approx
A
approximately (abbreviation)
20
Q
appt
A
appointment (med. abbreviation)
21
Q
ASA
A
acetylsalicylic acid / aspirin (med. abbreviation)
22
Q
ASAP
A
as soon as possible (med. abbreviation)
23
Q
BC
A
birth control (med. abbreviation)
24
Q
bid
A
twice a day (med. abbreviation)
25
BM
bowel movement (abbreviation)
26
BP
blood pressure (med. abbreviation)
27
BPM
beats per minute (med. abbreviation)
28
BS
blood sugar (med. abbreviation)
29
c̅
with (med. abbreviation)
30
CC
chief complaint (med. abbreviation)
31
CMA (AAMA)
certified medical assistant (American Association of Medical Assistants)
32
CCMA (NHA)
certified clinical medical assistant (National Healthcareer Association)
33
c/o
complains of (med. abbreviation)
34
d
day (med. abbreviation)
35
/d
per day (med. abbreviation)
36
d/c
discontinue (med. abbreviation)
37
DOB
date of birth (med. abbreviation)
38
DVA
distance visual acuity (med. abbreviation)
39
ED
emergency department (med. abbreviation)
40
EDD
expected date of delivery (med. abbreviation)
41
F/U
follow up (med. abbreviation)
42
Fx
fracture (med. abbreviation)
43
GYN
gynecology (med. abbreviation)
44
h | hr
hour (med. abbreviation)
45
H/A
headache (med. abbreviation)
46
HBP
high blood pressure (med. abbreviation)
47
Hep B
hepatitis B vaccine (med. abbreviation)
48
H₂O
water (med. abbreviation)
49
HR
heart rate (med. abbreviation)
50
ht
height (med. abbreviation)
51
ID
interdermal (med. abbreviation)
52
IM
intramuscular (med. abbreviation)
53
IV
intravenous (med. abbreviation)
54
LBP
lower back pain (med. abbreviation)
55
LMP
last menstrual period (med. abbreviation)
56
med, meds
medication, medications (med. abbreviation)
57
min
minute (med. abbreviation)
58
MMR
measles, mumps, and rubella (med. abbreviation)
59
N/A
not applicable (med. abbreviation)
60
N/C
no complaints (med. abbreviation)
61
neg
negative (med. abbreviation)
62
NKA
no known allergies (med. abbreviation)
63
NKDA
no known drug allergies (med. abbreviation)
64
N&V
nausea and vomiting (med. abbreviation)
65
NVA
near visual acuity (med. abbreviation)
66
OTC
over the counter (nonprescription medication)
(med. abbreviation)
67
OV
office visit (med. abbreviation)
68
P
pulse (med. abbreviation)
69
pc
after meals (med. abbreviation)
70
per
by or through (med. abbreviation)
71
po | PO
by mouth (med. abbreviation)
72
pos
positive (med. abbreviation)
73
postop
postoperative (after surgery)
(med. abbreviation)
74
preop
preoperative (before surgery)
(med. abbreviation)
75
prn
as needed (med. abbreviation)
76
Pt | pt
patient (med. abbreviation)
77
qh
every hour (med. abbreviation)
78
qid
four times a day (med. abbreviation)
79
QNS
quantity not sufficient (med. abbreviation)
80
R
respiration (med. abbreviation)
81
RMA
registered medical assistant
82
Rx
prescription (med. abbreviation)
83
s̅
without (med. abbreviation)
84
subcut
subcutaneous (med. abbreviation)
85
SOB
shortness of breath (med. abbreviation)
86
STAT
immediately (med. abbreviation)
87
T
temperature (med. abbreviation)
88
tab, tabs
tablet, tablets (med. abbreviation)
89
temp
temperature (med. abbreviation)
90
tid
three times a day (med. abbreviation)
91
WNL
within normal limits (med. abbreviation)
92
w/o
without
93
wt
weight (med. abbreviation)
94
abd
abdomen (med. abbreviation)
95
EENT
eye, ear, nose, and throat (med. abbreviation)
96
GI
gastrointestinal (med. abbreviation)
97
Ⓛ | lt
left (med. abbreviation)
98
LA (circled)
left arm (med. abbreviation)
99
LL (circled)
left leg (med. abbreviation)
100
LLQ
lower left quadrant (med. abbreviation)
101
LRQ
lower right quadrant (med. abbreviation)
102
LUQ
left upper quadrant (med. abbreviation)
103
® | rt
right (med. abbreviation)
104
RA (circled)
right arm (med. abbreviation)
105
RL (circled)
right leg (med. abbreviation)
106
RLQ
right lower quadrant (med. abbreviation)
107
RUQ
right upper quadrant (med. abbreviation)
108
Dx
diagnosis (med. abbreviation)
109
H/O
history of (med. abbreviation)
110
H&P
history and physical (med. abbreviation)
111
Hx
history (med. abbreviation)
112
PE | Px
physical examination (med. abbreviation)
113
Sx
symptoms (med. abbreviation)
114
Tx
treatment (med. abbreviation)
115
CA
cancer (med. abbreviation)
116
CAD
coronary artery disease (med. abbreviation)
117
CHF
congestive heart failure (med. abbreviation)
118
COPD
chronic obstructive pulmonary disease (med. abbreviation)
119
DM
diabetes mellitus (med. abbreviation)
120
HTN
hypertension (med. abbreviation)
121
IBS
irritable bowel syndrome (med. abbreviation)
122
OM
otitis media (infection in the middle ear)
(med. abbreviation)
123
TB
tuberculosis (med. abbreviation)
124
URI
upper respiratory infection (med. abbreviation)
125
UTI
urinary tract infection (med. abbreviation)
126
mL
milliliter (med. abbreviation)
127
