Medical Medical TerminologyTerminologyA Programmed Learning Approach toA Programmed Learning Approach to the Language of Health Care, 2 the Language of Health Care, 2nd nd Edition EditionChapter 2:Chapter 2:Health Care RecordsHealth Care Records2History and Physical History and Physical (H&P)(H&P)Document of medical history and Document of medical history and fndings from physical examinationfndings from physical examinationIncludesIncludes!u"#ecti$e information % history!u"#ecti$e information % historyo"tained from patient including o"tained from patient including his&her personal perceptionshis&her personal perceptions'"#ecti$e information % physical'"#ecti$e information % physicalfacts and o"ser$ations made "y an facts and o"ser$ations made "y an examinerexaminer3History (Hx)History (Hx)(ecord of the patient)s personal (ecord of the patient)s personal medical history including past medical history including past in#uries, illnesses, operations, in#uries, illnesses, operations, defects, and ha"itsdefects, and ha"itsIncludes chief complaint, history Includes chief complaint, history of present illness, past history, of present illness, past history, family history, occupational family history, occupational history and re$ie* of systemshistory and re$ie* of systems4History (Hx) History (Hx) AbbreviationsAbbreviationsCCCCChief ComplaintChief Complaint+rief description of *hy patient is see,ing care+rief description of *hy patient is see,ing care c/oc/ocomplains ofcomplains of-sed in descri"ing complaint -sed in descri"ing complaintPIPI oror HPIHPIPresent Illness Present Illness or or History of Present IllnessHistory of Present Illness.otation of duration and se$erity of complaint .otation of duration and se$erity of complaintHo* "ad is it/ Ho* long ha$e they had it/ Ho* "ad is it/ Ho* long ha$e they had it/SxSx symptomsymptomE$idence of illness that the patient reports E$idence of illness that the patient reports5History (Hx) History (Hx) AbbreviationsAbbreviationsPH PH or or PMHPMHPast History Past History oror Past 0edical HistoryPast 0edical History.otation of surgeries, in#uries, .otation of surgeries, in#uries, physical defects, medications, physical defects, medications, allergiesallergiesCH!CH!usual childhood diseasesusual childhood diseases"#A"#Ano ,no*n allergiesno ,no*n allergies"#!A"#!A
no ,no*n drug allergiesno ,no*n drug allergies1continued2 1continued26History (Hx) History (Hx) AbbreviationsAbbreviations$H$H
3amily History3amily History.otes a"out the state of health of .otes a"out the state of health of immediate family mem"ersimmediate family mem"ersExample 3H father, age 45, mother,Example 3H father, age 45, mother, age 46, "rother, age 72, all L89 age 46, "rother, age 72, all L89A&%A&%
ali$e and *ellali$e and *ell&&%&&%
li$ing and *ellli$ing and *ell1continued2 1continued27History (Hx) History (Hx) AbbreviationsAbbreviationsSHSH!ocial History!ocial History(ecreational interests, ho""ies, use (ecreational interests, ho""ies, use of to"acco&drugsof to"acco&drugs'H'H'ccupational History'ccupational History9or, ha"its that may in$ol$e *or, 9or, ha"its that may in$ol$e *or, related ris,srelated ris,s('S('S oror S(S((e$ie* of !ystems (e$ie* of !ystems oror !ystems (e$ie*!ystems (e$ie*:uestions related to function of the :uestions related to function of the "ody systems"ody systems1continued2 1continued28Physical )xam (Px or Physical )xam (Px or P))P))Document of physical Document of physical examination of a patient including examination of a patient including notations of positi$e and negati$e notations of positi$e and negati$e fndingsfndingsIncludes results of diagnostic testingIncludes results of diagnostic testing!ign % o"#ecti$e e$idence of disease!ign % o"#ecti$e e$idence of disease9Physical )xam Physical )xam AbbreviationsAbbreviationsH))"TH))"Thead, eyes, ears, nose, head, eyes, ears, nose, and throatand throatP)((&AP)((&Apupils e;ual, round, and pupils e;ual, round, and reacti$e to light and reacti$e to light and accommodationaccommodation"A!"A!no acute distressno acute distress%"&%"&*ithin normal limits*ithin normal limits10History and PhysicalHistory and PhysicalIm*ression (IMP) Im*ression (IMP)!iagnosis (!x) !iagnosis (!x)Assessment (A) Assessment (A)identifcation of a disease or condition afteridentifcation of a disease or condition after e$aluation of all su"#ecti$e and o"#ecti$ee$aluation of all su"#ecti$e and o"#ecti$e information information(+le o+t ((/') (+le o+t ((/')aa diferential diagnosis diferential diagnosis noted *hen one ornoted *hen one or more diagnoses are suspect< re;uiresmore diagnoses are suspect< re;uires further testing to $erify or eliminate eachfurther testing to $erify or eliminate each possi"ility possi"ility11History and PhysicalHistory and PhysicalP&A",P&A",()C'MM)"!ATI'",()C'MM)"!ATI'", oror!ISP'SITI'"!ISP'SITI'"outline of the treatment plan designed outline of the treatment plan designed to remedy the patient)s condition, to remedy the patient)s condition, *hich includes instructions to the *hich includes instructions to the patient and orders for medications, patient and orders for medications, diagnostic tests, or therapiesdiagnostic tests, or therapies1continued2 1continued212S'AP Progress "otesS'AP Progress "otesProgress notes made after the initial Progress notes made after the initial history and physical is recorded= >he history and physical is recorded= >he letters represent the order in *hich letters represent the order in *hich progress is notedprogress is notedSSs+b-ectives+b-ective % % that *hich the patient descri"es that *hich the patient descri"es''ob-ectiveob-ective % % o"ser$a"le information, such aso"ser$a"le information, such as test results, "lood pressure readings, etc= test results, "lood pressure readings, etc=A A assessmentassessment % % progress and e$aluation of theprogress and e$aluation of the e?ecti$eness of the plan e?ecti$eness of the planP P *lan*lan % % decision to proceed or alter strategy decision to proceed or alter strategy13Common Hos*ital Common Hos*ital (ecords(ecordsHistory and PhysicalHistory and PhysicalPhysician)s ordersPhysician)s ordersDiagnostic tests&la"oratory reportsDiagnostic tests&la"oratory reports.urse)s notes.urse)s notesPhysician)s progress notesPhysician)s progress notesConsultation reportConsultation report'perati$e report'perati$e reportPathology reportPathology reportAnesthesiologist)s reportAnesthesiologist)s report14!iagnostic Imaging !iagnostic Imaging ModalitiesModalitiesI'"I.I"/ IMA/I"/I'"I.I"/ IMA/I"/ A process that changes the electrical A process that changes the electrical charge of atoms *ith a possi"le e?ect on charge of atoms *ith a possi"le e?ect on "ody cells< o$erexposure can ha$e "ody cells< o$erexposure can ha$e harmful side e?ects, e=g=, cancerharmful side e?ects, e=g=, cancer (ADI'@(APHA 1BC(AA2 (ADI'@(APHA 1BC(AA2C'0P->ED >'0'@(APHAC'0P->ED >'0'@(APHA or orC'0P->ED ABIAL >'0'@(APHA C'0P->ED ABIAL >'0'@(APHA.-CLEA( 0EDICI.E I0A@[email protected]( 0EDICI.E I0A@I.@ or or(ADI'.-CLIDE '(@A. I0A@I.@ (ADI'.-CLIDE '(@A. I0A@I.@15!iagnostic Imaging !iagnostic Imaging ModalitiesModalities"'"I'"I.I"/ IMA/I"/"'"I'"I.I"/ IMA/I"/ an imaging process that an imaging process that presents no apparent ris, presents no apparent ris, [email protected]>IC (E!'.A.CE I0A@I.@[email protected]>IC (E!'.A.CE I0A@I.@!'.'@(APHA!'.'@(APHA1continued2 1continued216Common Terms Common Terms (elated to !isease(elated to !iseaseacute $s= chronicacute $s= chronic"enign $s= malignant"enign $s= malignantlocaliDed $s= systemiclocaliDed $s= systemicexacer"ation $s= remissionexacer"ation $s= remissionprogressi$eprogressi$erecurrentrecurrentdegenerati$edegenerati$e17Common Terms Common Terms (elated to !isease(elated to !iseasesymptom 1su"#ecti$e2symptom 1su"#ecti$e2sign 1o"#ecti$e2sign 1o"#ecti$e2diagnosis 1through ,no*ing2diagnosis 1through ,no*ing2syndrome 1running together2syndrome 1running together2prognosis 1"efore ,no*ing2prognosis 1"efore ,no*ing2etiology 1study of cause2etiology 1study of cause2idiopathic 1disease of indi$idual2idiopathic 1disease of indi$idual2se;uelase;uela1continued2 1continued218Common Terms Common Terms (elated to !isease(elated to !iseasegood $s= malaisegood $s= malaisefe"rile $s= afe"rilefe"rile $s= afe"rilemar,edmar,ede;ui$ocale;ui$ocalnoncontri"utorynoncontri"utoryunremar,a"leunremar,a"lemor"iditymor"iditymortalitymortality1continued2 1continued219Common Patient Care Common Patient Care AbbreviationsAbbreviations-se only those accepta"le to -se only those accepta"le to *or,place*or,placeemergency facilityemergency facility)(, )C)(, )Cplace to reco$er after surgeryplace to reco$er after surgeryPA(, PACPA(, PACregistered "ed patientregistered "ed patientIPIPcare "efore surgerycare "efore surgery*reo*, *re0o**reo*, *re0o*patientpatient*t*t*ellCde$eloped, *ellCnourished*ellCde$eloped, *ellCnourished%!%"%!%""athroom pri$ileges"athroom pri$ileges1(P1(P20Common Patient Care Common Patient Care AbbreviationsAbbreviationsshortness of "reathshortness of "reathS'1S'1treatmenttreatmentTx, TrTx, Trtemperature, pulse, temperature, pulse, T, P, T, P, respiration, "lood pressure respiration, "lood pressure(, (, 1P 21P 2
1$ital signs21$ital signs23S3S increase increase decreasedecreasedegree or hourdegree or hourEEpound or num"er signpound or num"er signFF1continued2 1continued221)rror Prone )rror Prone Abbreviations and Abbreviations and SymbolsSymbols0edical errors caused "y illegi"le *riting 0edical errors caused "y illegi"le *riting and misinterpretations of a""re$iations and misinterpretations of a""re$iations and sym"ols ha$e led health care and sym"ols ha$e led health care agencies, such as the Goint Commission on agencies, such as the Goint Commission on Accreditation of Healthcare 'rganiDations Accreditation of Healthcare 'rganiDations 1GCAH'2, to re;uire that medical facilities 1GCAH'2, to re;uire that medical facilities pu"lish lists of authoriDed a""re$iations pu"lish lists of authoriDed a""re$iations for use "y all personnel, including a list of for use "y all personnel, including a list of a""re$iations and sym"ols that are a""re$iations and sym"ols that are unaccepta"le=unaccepta"le=22)rror Prone )rror Prone Abbreviations and Abbreviations and SymbolsSymbols45 d 45 d every dayevery daymista,en for ;=i=d *hen the period mista,en for ;=i=d *hen the period after the H;I is sloppily *ritten to after the H;I is sloppily *ritten to loo, li,e an HiIloo, li,e an HiIspell out HdailyIspell out HdailyI45o5d5 45o5d5 every other dayevery other daymista,en for ;=d *hen the HoI is mista,en for ;=d *hen the HoI is mista,en for a periodmista,en for a periodspell out He$ery other dayIspell out He$ery other dayI1continued2 1continued223)rror Prone )rror Prone Abbreviations and Abbreviations and SymbolsSymbols!C, !/C !C, !/C discharge, discontin+edischarge, discontin+emista,en for HdiscontinueI *hen follo*ed "ymista,en for HdiscontinueI *hen follo*ed "y medications prescri"ed at the time ofmedications prescri"ed at the time of discharge dischargespell out HdiscontinueI or HdischargeIspell out HdiscontinueI or HdischargeI6, 7 6, 7 greater than, less thangreater than, less thanmista,en for each other mista,en for each otherspell out Hgreater thanI or Hless thanIspell out Hgreater thanI or Hless thanI1continued2 1continued224)rror Prone )rror Prone Abbreviations and Abbreviations and SymbolsSymbolsAS, A!, Ale8t ear, right ear, both AS, A!, Ale8t ear, right ear, both earsears'S, '!, ' le8t eye, right eye, both 'S, '!, ' le8t eye, right eye, both eyeseyesmista,en for each other mista,en for each otherspell out Hleft ear,I Hright eye,I etc=spell out Hleft ear,I Hright eye,I etc=SC SC or or S9 S9 s+bc+taneo+ss+bc+taneo+smista,en for !L 1su"lingual2 or H4 e$eryI mista,en for !L 1su"lingual2 or H4 e$eryIspell out Jsu"cutaneouslyH or use su"C:spell out Jsu"cutaneouslyH or use su"C:1continued2 1continued225Pharmace+tical Pharmace+tical Abbreviations and Abbreviations and SymbolsSymbols0etric0etriccc 1cu"ic centimeter2cc 1cu"ic centimeter2cm 1centimeter2cm 1centimeter2g g oror gm 1gram2gm 1gram2,g 1,ilogram2,g 1,ilogram2L 1liter2L 1liter2mg 1milligram2mg 1milligram2ml ml oror mL 1milliliter2 mL 1milliliter2 Note: Note: K cc L K mLK cc L K mLmm 1millimeter2mm 1millimeter2cu mm cu mm or or mmmm77 1cu"ic millimeter21cu"ic millimeter226Pharmace+tical Pharmace+tical Abbreviations and Abbreviations and SymbolsSymbolsApothecaryApothecaryM oD 1Muid ounce2M oD 1Muid ounce2gr 1grain2gr 1grain2gt 1drop2gt 1drop2gtt 1drops2gtt 1drops2dr 1dram2dr 1dram2oD 1ounce2oD 1ounce2l" or F 1pound2l" or F 1pound2;t 1;uart2;t 1;uart21continued2 1continued227Medication Medication Administration 0 !r+g Administration 0 !r+g $orms$orms!olid and !emisolid 3orms!olid and !emisolid 3orms>a"let 1ta"2 >a"let 1ta"2Capsule 1cap2 Capsule 1cap2!uppository 1suppos2 !uppository 1suppos2Li;uid 3ormsLi;uid 3orms3luid 3luidParenteral 1ID, su"C:, I0, IN2 Parenteral 1ID, su"C:, I0, IN2Cream, lotion, ointment Cream, lotion, ointment'ther deli$ery systems 'ther deli$ery systems>ransdermal >ransdermalImplant Implant28Parenteral !r+g Parenteral !r+g AdministrationAdministration29The Prescri*tionThe Prescri*tionPhysician)s *ritten direction for Physician)s *ritten direction for dispensing or administering a dispensing or administering a medication for a patientmedication for a patient0ust "e *ritten in a specifc 0ust "e *ritten in a specifc formatformat(x(x!ym"ol at "eginning of prescription !ym"ol at "eginning of prescription!tands for recipe !tands for recipe30!r+g "ames!r+g "amesChemical nameChemical name % assigned to % assigned to drug at the time it is formulateddrug at the time it is formulated/eneric name/eneric name % the oOcial, % the oOcial, nonproprietary name gi$en a nonproprietary name gi$en a drugdrugTradeTrade or or brandbrand % the % the manufacturerPs name for a drugmanufacturerPs name for a drug31!r+g "ames!r+g "ames3or example3or exampleChemical name:Chemical name: KCQ7C1R,SCdihydroCKCKCQ7C1R,SCdihydroCKCethylCSCoxoC7CpropylCKHCpyraDoloQ6,7CethylCSCoxoC7CpropylCKHCpyraDoloQ6,7CpyrimidinC4Cyl2C6CpyrimidinC4Cyl2C6CethoxyphenylTsulfonylTC6CethoxyphenylTsulfonylTC6CmethylpiperaDine citratemethylpiperaDine citrate/eneric name:/eneric name: sildenaflsildenaflTradeTrade or or 1rand name:1rand name: NiagraNiagra1continued2 1continued232Sam*le Prescri*tionSam*le Prescri*tion33Military TimeMilitary Time34CorrectionsCorrectionsCareful clarifcation of an error Careful clarifcation of an error *hen ma,ing an entry in a *hen ma,ing an entry in a medical record is essentialmedical record is essentialIncludeIncludeDateDate>he a""re$iation HcorrI>he a""re$iation HcorrIInitials of person ma,ing correctionsInitials of person ma,ing correctionsDo not use correction MuidUDo not use correction MuidU35Pro*er Correction o8 a Pro*er Correction o8 a Medical (ecordMedical (ecord
