Medical Terminology - CHAPTER 2: Health Care Records (PT702)

44 flashcards · Biology · by Jack Shi

The record that serves as a cornerstone for patient care is the history and physical (H&P). The H&P documents the patient’s medical history and findings from the physical examination. It is usually the first document to be generated when a patient presents for care, and is most often recorded at a new patient visit or as part of a consultation.
The first portion of the H&P, the history (Hx), documents subjective information from the patient’s personal statement about his or her medical history and includes information regarding past injuries, illnesses, operations, defects, and habits. It begins with the chief complaint (CC), the patient’s reason for seeking medical care. The chief complaint is usually brief, and is often recorded in the patient’s own words, which are indicated by quotation marks (e.g., CC:“flu”). Often, especially in…
Information about the patient’s past history (PH),or past medical history (PMH), is recorded next. This includes a record of information about the patient’s past illnesses, starting with childhood, and it includes surgical operations, injuries, physical defects, medications, and allergies. The abbreviation UCHD (usual childhood diseases) is used here to record that the patient had all the “usual” or commonly contracted illnesses during childhood. The abbreviation NKA (no known allergies), or NK…
The history is complete after documenting the patient’s answers to questions related to the review of systems (ROS), or a systems review (SR), a head-to-toe review of the functions of all body systems. This review makes it possible to evaluate other symptoms that may not have been previously mentioned.
After the subjective data are recorded, the provider begins a physical examination (PE), or a physical (Px), to obtain objective information, facts that can be seen or detected by testing. Signs, or objective evidence of disease, are documented, and selected diagnostic tests are performed or ordered when further evaluation is necessary. Several abbreviations are used to document the findings of the physical examination, such as HEENT (head, eyes, ears, nose, and throat), PERRLA (pupils equal, r…
The identification of a disease or condition is recorded in the impression (IMP), diagnosis (Dx), or assessment (A), which is made after the evaluation of all subjective and objective data. Often, when one or more diagnoses are in question, a differential diagnosis is made using the abbreviation R/O (rule out). The possible conditions are identified, and further investigation, often involving diagnostic tests and procedures, is done to rule out or eliminate each suspect and to verify the final…
Final notations include the health care provider’s plan (P), also called the recommendation or disposition. Here, the provider outlines strategies designed to remedy the patient’s condition, including instructions to the patient and orders for medications, diagnostic tests, or therapies.
Often, physicians are required to dictate a current H&P before admitting a patient to the hospital (e.g., for elective surgery). When the patient is to have surgery, this report is often called a preoperative H&P.
After the initial H&P is recorded, progress notes are used to document the patient’s continued care.The SOAP method of documenting a patient’s progress is most common. The letters represent the order in which progress is noted as each complaint or problem is addressed: S: Subjective - that which the patient describes O: Objective - observable information (e.g., test results and blood pressure readings) A: Assessment - patient’s progress and evaluation of the plan’s effectiveness; any newfound p…
COMMON ABBREVIATIONS USED IN THE HISTORY AND PHYSICAL AND PROGRESS NOTES A = assessment A&W = alive and well CC = chief complaint c/o = complains of Dx = diagnosis FH = family history HEENT = head, eyes, ears, nose, and throat H&P = history and physical HPI, PI = history of present illness, present illness Hx = history IMP = impression L&W = living and well NAD = no acute distress NKA, NKDA = no known allergies, no known drug allergies O = objective information OH = occupational history P = pla…
The H&P, or history and physical, is the first document generated in the care of a patient. It is divided into two categories: the Hx, or history, which provides all subjective information obtained from the patient, including his or her own perceptions; and the Px, or physical, or PE, or physical examination, which records all objective information that can be seen or verified by the examiner.
The first thing that is noted in the history is the CC, or chief complaint, or what the patient c/o, or complains of. It is a brief explanation of why the patient is seeking medical care. Further details about the complaint are noted in the PI, or present illness, or HPI, or history of present illness, to report how long the patient has had the complaint and how bad it is. All subjective evidence of disease that the patient reports is noted as Sx, or symptoms.
The history continues by gathering information regarding past injuries, illnesses, operations, physical defects, medications, and allergies in the PH, or past history, or PMH, or past medical history. UCHD notes that the patient had the usual childhood diseases, or commonly contracted illnesses during childhood. NKA, or no known allergies, and NKDA, or no known drug allergies, indicate that the patient has had no known allergic reaction to a previously administered drug.
“Father, age 58, mother, age 54, brother, age 32, all L&W” is an example of a FH, or family history. Notes about recreational interests, hobbies, and use of tobacco and drugs, such as alcohol, are noted in the SH, or social history. Work habits that may involve health risks are included in the OH, or occupational history. The history is complete after the patient answers questions related to a review of the functions of the body systems in the ROS, or review of systems, or SR, systems review.
The second portion of the H&P is the Px, or physical, or PE, or physical examination. Objective evidence of disease, called signs, are documented, and selected tests are ordered and the findings recorded. Common abbreviations include HEENT, which means head, eyes, ears, nose, and throat; PERRLA, which means pupils equal, round, reactive to light and accommodation; WNL, which means within normal limits; and NAD, which indicates no acute distress.
The identification of a disease or condition is recorded in the IMP, or impression; the Dx, or diagnosis; or the A, or assessment. This is made after all subjective and objective data are evaluated. When one or more diagnoses are in question, a differential diagnosis is made using the abbreviation R/O, or rule out.
An outline of strategies designed to remedy the patient’s condition is noted in the provider’s P, or plan, which is also called a recommendation or disposition. This section includes the provider’s instructions to the patient and orders for medications, diagnostic tests, or therapies.
After the initial history and physical is recorded, progress notes are used for further documentation of the patient’s care. The letters “SOAP” represent the order in which progress is noted: S: subjective; that which the patient describes O: objective; observable information (e.g., test results or blood pressure readings) A: assessment; patient’s progress and evaluation of the effectiveness of the plan P: plan; decision to proceed or alter the plan strategy
The history and physical is often the first document entered into the patient’s hospital record and is commonly required before elective admission for surgery. Physician’s orders list the directives for care prescribed by the doctor who is attending to the patient. The nurse’s notes and physician’s progress notes chronicle the care throughout the patient’s stay. In a difficult case, a specialist may be called in by the attending physician,and a consultation report is filed. If a surgical remedy…
The final hospital document, which is recorded at the time of discharge, is the discharge summary (also termed the clinical resume, clinical summary, or discharge abstract). It is a summary of the patient’s hospital care, including the date of admission, diagnosis, course of treatment, final diagnosis, and date of discharge.
MEDICAL IMAGING XR = radiography or x-ray CXR = chest x-ray MRI / MRA = magnetic resonance imaging, magnetic resonance angiography CT / CAT = computed tomography, computed axial tomography US = sonography or diagnostic ultrasound
DISEASE TERMS acute = sharp; having intense, often severe symptoms and a short course chronic = a condition that develops slowly and persists over a period of time benign = mild or noncancerous malignant = harmful or cancerous degeneration = gradual deterioration of normal cells and body functions degenerative disease = any disease in which deterioration of the structure or function of tissue occurs diagnosis = determination of the presence of a disease based on an evaluation of symptoms, signs…
Originating from the Latin word for a mark, the term sign is used to describe objective evidence of disease that can be seen or verified by an examiner. The subjective evidence of disease that is perceived by the patient is a symptom. Many different signs and symptoms manifest disease in the body. The term malaise is used to describe a patient who feels unwell. A patient is considered to be febrile if he or she has an increase in body temperature, and to be afebrile if he or she is without a fe…
Some conditions have intense, often severe or acute onset, whereas others that are chronic develop slowly and persist over time. A condition is considered to be progressive when the symptoms and signs advance with increased severity. A flare-up, or exacerbation, occurs when there is an increase in the severity of symptoms. A condition is said to be in remission during the period in which signs and symptoms have stopped. The term recurrent describes a return of symptoms and signs after a period…
Degenerative disease occurs as a result of gradual deterioration of tissue with loss of function. The prefix de-, meaning from, down, or not, is used in the term describing this process: degeneration.
The cause or etiology of a disease is often unknown. A condition is considered to be idiopathic when there is no clear identifying cause. If a condition is cancerous, it is termed malignant, and if it is noncancerous, it is benign. A patient with significant weakness can be said to have marked weakness.
The doctor makes a diagnosis when naming a disease and gives a prognosis when predicting its likely outcome.
A prophylaxis is a process or measure that prevents disease.
The term describing a combination of symptoms and signs that give a distinct clinical picture is called a syndrome. For example, hot flashes, weight gain, mood swings, and irregular menstruation are signs and symptoms that indicate a woman is going through menopause, a condition known as menopausal syndrome.
A sequel is something that follows something else. The medical term that refers to a disorder or condition that results from a previous disease or injury is called sequela. The plural of sequela is sequelae.
When patient care data are not related to bringing on or causing a condition, they are said to be noncontributory. Similarly, information that is not significant or out of the ordinary is said to be unremarkable.
MEDICAL CARE FACILITIES 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 = postanesthetic recovery post-op or postop = postoperative (after surgery) pre-op or preop = preoperative (before surgery) RTC = return to clinic RTO = return to office
PATIENT CARE B = bilateral BRP = bathroom privileges CP = chest pain DC or D/C = discharge, discontinue ETOH = ethyl alcohol L = left R = right m = murmur 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 or y.o. = year old # = number or pound C = Celsius, centigrade F = Fahrenheit
The patient seeking emergency care is often seen in the ECU, or emergency care unit, most commonly known as the hospital ER. Depending on the circumstances of the accident or illness, the patient is treated as an OP, or outpatient, or is admitted as an IP, or inpatient. Sometimes, in a critical case, the patient is transferred directly to the ICU, or intensive care unit. If surgery is necessary, it is performed in the OR, or operating room, after which a period of recovery is made in the PACU,…
While hospitalized, the pt, or patient, is seen by the attending physician and is cared for by the nursing staff. The doctor writes orders for all Tx, or treatment, including how often the VS, or vital signs (T, or temperature; P, or pulse; R, or respiration; and BP, or blood pressure), are to be taken and whether the patient is to have BRP, or bathroom privileges. The nurses must document the care and report any abnormal findings, such as CP, or chest pain, and SOB, or shortness of breath. The…
ROUTES OF MEDICATION ADMINISTRATION parenteral = by injection intradermal (ID) = within the skin intramuscular (IM) = within the muscle intravenous (IV) = within the vein subcutaneous (SC, SQ, or sub-Q) = under the skin
The parenteral route of administration is by injection: ID, or intradermal; IM, or intramuscular; IV, or intravenous; or sub-Q, or subcutaneous.
A prescription is a written direction by a physician for dispensing or administering a medication to a patient. It is an order to supply a named patient with a particular drug of a specific strength and quantity, along with precise instructions for administration. The prescription is a legal document that must be written in a specific format that includes the name, strength, and amount of the drug, its indications for use, and the Sig:, a label with instructions to the patient.
Every drug is assigned a chemical name at the time it is invented in the laboratory. It is the formula for the drug and is written exactly according to its chemical structure. The generic name is the official, nonproprietary name given to a drug. The trade or brand is the manufacturer’s name for a drug.
Rx is a symbol meaning recipe or prescription. A prescription is a direction by a physician for dispensing a medication or drug to a patient. It includes the name, strength, and quantity of a drug along with the indication for its use and the Sig:, or the label that provides specific instruction for administration. Brand and generic names must be provided on all medication orders. The generic name is the official, nonproprietary name for a drug, and the trade or brand name is given to a drug by…
TIME AND FREQUENCY a = before a.c. = before meals a.m. = before noon b.i.d. = twice a day d = day h = hour h.s. = at the hour of sleep (bedtime) noc. = night p = after p.c. = after meals p.m. = after noon p.r.n. = as needed q = every q.d. = every day qh = every hour q2h = every 2 hours q.i.d. = four times a day q.o.d. = every other day STAT = immediately t.i.d. = three times a day wk = week yr = year
MISCELLANEOUS AD = right ear ad lib. = as desired amt = amount aq = water AS = left ear AU = both ears c = with NPO = nothing by mouth OD = right eye OS = left eye OU = both eyes per = by or through p.o. = by mouth PR = through rectum PV = through vagina Rx = recipe; prescription s = without Sig = label; instruction to the patient ss = one-half wa = while awake x = times or for; x6 means six times while x2d means for two days
Ante, meaning before, is abbreviated as a. Before noon is abbreviated a.m., and a.c. stands for before meals. Post, meaning after, is abbreviated p. After noon is abbreviated p.m., and p.c. stands for after meals. Day is abbreviated d, night as noc., and bedtime as h.s.. Some medications must be taken immediately or STAT. If a medication is taken p.r.n., it is taken as needed. If the patient can have as much as desired, the abbreviation is ad lib.. Sometimes, such as before surgery, the doctor…
Sinister, meaning left, and dexter, meaning right, are referenced in abbreviations for the eyes and ears. The right eye, or oculus dexter, is abbreviated as OD. The left eye, or oculus sinister, is abbreviated OS. Oculi unitas, referring to both eyes, is abbreviated OU. Auris refers to ear. The right ear is abbreviated as AD, the left ear as AS, and both ears as AU. Because abbreviations related to the eyes and ears have been misinterpreted, it is recommended that they be spelled out instead.