Medical terminology ch 2 health care records

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Ghoelix
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Medical terminology ch 2 health care records
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2013-02-02 14:44:10
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medical terminology chapter 2 health care records
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  1. H&P
    History and physical.
  2. Hx
    History

    Subjective information from patient's personal statement about his or her medical history.  Includes information regardign past injuries, illnesses, operations, defects, and habits.
  3. CC
    Chief Complaint

    Usually brief and recorded in patients own words.
  4. HPI / PI
    History of Present Illness

    Duration and severity of complaint.
  5. Sx
    Symptoms

    Subjective evidence of illness which indicates what patient is experiencing. 
  6. PHM / PH
    Past Medical History

    Includes a record of information about patient's past illnesses, starting with childhood, includes surgical operations, injuries, physcal defects, medications, and allergies.  UCHD ( usual childhood diseases ) is often used here to indicate that the patient had usual childhood diseases as a child.
  7. UHCD
    Usual childhood diseases.

    Indicates patient had usual childhood diseases as a child.
  8. NKA
    No Known Allergies
  9. NKDA
    No Known Drug Allergies
  10. FH
    Family History

    State of health of Immediate family members.
  11. SH
    Social History

    Patient's recreational activities; hobbies, tobacco, alcohol, drug use.
  12. OH
    Occupational History

    Record of work habits that may involve health risks.
  13. ROS / SR
    Review of Symptoms

    A head to toe review of the function of all the body's systems.  This review makes it possible to evaluate other symptoms that may not have been mentioned.
  14. PE / Px
    Physical Examination

    Physical examination of patient.  Objective information about patient gained from examination or testing.
  15. Signs
    Objective evidence of disease.
  16. HEENT
    Head, Eyes, Ears, Nose, Throat
  17. PERRLA
    Pupils Equal, Round and Reactive to Light and Accommodation.
  18. NAD
    No Acute Distress
  19. WNL
    Within Normal Limits
  20. A
    assessment
  21. IMP
    impression
  22. DX
    diagnosis
  23. R/O
    Rule Out

    When more than one diagnosis is possible, attempts are made to rule out diagnoses to identify the main diagnosis.
  24. P
    Plan / recommendation / disposition

    Strategies are outlined to remedy the patient's condition, including instructions to the patient and orders for medications, diagnostic tests, or therapies.
  25. Preoperative H&P
    A History and Physical that is done prior to a patient undergoing surgery to be certain the patient is healthy enough for surgery.
  26. SOAP
    Method of documenting a patient's progress, the letters represent the order in which progress is noted as each complaint or problem is addressed.

    • S - Subjective - what the patient describes
    • O - Objective - observable information; test results, blood pressure readings, etc.
    • A - Assessment - patient's progress and evaluation of plan's effectiveness, newfound problems or diagnoses are also noted here
    • P - Plan - decision to proceed or to alter the plan strategy
  27. A&W
    Alive and well
  28. L&W
    Living and well
  29. c/o
    Complains of
  30. IMP
    Impression
  31. O
    Objective information

    Information gained by observation, examination, or testing.  This is different and separate from information the patient gives.
  32. S
    Subjective

    The patient describing, in their own words, their problem, symptoms, complaint.
  33. PI
    Present Illness
  34. Progress Notes
    Documentation of patient's care.
  35. Physician's orders
    List of directives for care prescribed by the doctor who is attending to the patient.
  36. Nurse's notes
    Chronicle care through the patient's stay.
  37. Physician's progress notes
    Chronicle care through the patient's stay.
  38. Consultation report
    Report made by consulting physician in difficult cases.
  39. Operative report
    a detailed account of the operation, including the method of incision, technique, instruments used, types of suture, method of closure, patient's responses during procedure and at time of recovery.
  40. Anesthesiologist's report
    Report covering anesthesia details, including drugs used, dosage and time given, patient's vital status throughout procedure.
  41. Informed consent form
    Form signed by the patient showing that he or she has been advised of the risks and benefits of the proposed treatment as well as any alternatives.
  42. Ancillary report
    Reports noting additional procedures and therapies, including diagnostic tests and pathology reports.
  43. Discharge summary /
    Clinical resume /
    Clinical summary /
    Discharge abstract
    Summary of patient's hospital care, including date of admission, diagnosis, course of treatment, final diagnosis, and date of discharge.
  44. Ionizing
    A process that changes the electrical charge of atoms and has a possible effect on body cells.
  45. Radiology
    Category of imaging techniques.
  46. Common ionizing techniques:
    • Radiography ( xray )
    • Computed Tomography ( CT )
    • Nuclear medicine.
  47. Common NONionizing techniques
    • Magnetic Resonance Imaging ( MRI )
    • Sonography / ultrasonography ( US )
  48. Radiograph
    An xray image.
  49. CT - Computed tomography /
    CAT - Computed axial tomography
    Radiologic procedure which uses a machine ( called a scanner ) to examine a body site by taking a series of cross-sectional ( tomographic ) x-ray films in a full-circle rotation.  A computer then calculates and converts the separate images into a 3-dimensional picture.
  50. Nuclear Medicine Imaging /
    Radionuclide Organ Imaging
    Radioactive isotopes ( also called radionuclides ) or a substance tagged with a radioactive compounds which emit gamma rays are ingested ( swallowed ) by or injected into a patient.  A gamma camera detects the emitted radiation and produces an image of the emitted radiation.  This technique is useful for determining the size, shape, location and function of body organs such as the brain, lungs, bones, and heart.
  51. MRI - Magnetic Resonance Imaging
    A large magnet surrounds the patient which temporarily alters the alignment of Hydrogen atoms in the body, altering their alignment, then turning off and letting them realign.  The energy given off by this process is picked up by a scanner and converted into an image.  This method is useful for examining soft tissues, joints, brain, and spinal cord.
  52. MRA - Magnetic Resonance Angiography
    Magnetic resonance technology used to study blood flow.
  53. Sonography / US
    High frequency sound waves are bounced off internal structures, received by the transducer, then converted to an image to provide live images of the inside of a patient.  This technology is useful for viewing abdomen, reproductive organs, thyroid, parathyroid, and cardiovascular system.
  54. Contrast medium
    Substances which are swallowed, injected, introduced by IV or enema, which can move to or through parts of the body and will show up on imaging devices.
  55. -graphy
    Process of recording
  56. Radionuclide organ imaging
    Nuclear medicine

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