The Medical Record CHAPTER 4

History and Physical H & P  Document of medical history and findings from physical examination Includes:  Subjective information — History obtained from patient including his/her personal perceptions  Objective Information — Physical facts and observations made by an examiner

History (Hx)  Record of the patient’s personal medical history including past injuries, illnesses, operations, defects, and habits  Includes: chief complaint, history of present illness, past history, family history, occupational history and review of systems

History (Hx) Abbreviations CC Chief Complaint or c/o complains of Brief description of why patient is seeking care PI or HPI Present Illness/History of Present Illness Notation of duration and severity of complaint How bad is it? How long have they had it? Sx symptom Evidence of illness that the patient reports

History (Hx) Abbreviations PH, PMH Past History, Past Medical History Notation of surgeries, injuries, physical defects, medications, allergies UCHD usual childhood diseases NKA no known allergies NKDA no known drug allergies (continued)

History (Hx) Abbreviations SH Social History recreational interests, hobbies, use of tobacco/drugs OH Occupational History work habits that may involve work related risks ROS or SR Review of Systems, Systems Review questions related to function of the body systems HEENT head, eyes, ears, nose, throat (continued)

Physical Exam (Px or PE)  Document of physical examination of a patient including notations of positive and negative findings Includes: results of diagnostic testing Sign — objective evidence of disease

Physical Exam Abbreviations HEENT head, eyes, ears, nose, throat PERRLA pupils equal, round and reactive to light and accommodation NAD no acute distress, no appreciable disease WNL within normal limits

History and Physical Impression (IMP) Diagnosis (Dx) Assessment (A) identification of a disease or condition after evaluation of all subjective and objective information Rule out (R/O) a differential diagnosis noted when one or more diagnoses are suspect — requires further testing to verify or eliminate each possibility

History and Physical PLAN, 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 (continued)

Problem Oriented Medical Record (POMR)  Health record with focus on patient’s problem  Information organized for access at a glance  Documents thought processes of provider  Consists of four sections:  Database  Problem list  Initial plan  Progress notes

Common Patient Care Abbreviations difficulty breathing SOB Treatment or transfer Tx, Tr temperature, pulse, T, P, R, BP = respiration, blood pressure VS or vital signs increase  decrease  degree or hour° pound or number sign#

Error Prone Abbreviations and Symbols Medical errors caused by illegible entries and misinterpretations have led health care agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), to require that medical facilities publish lists of authorized abbreviations for use by all personnel, including a list of those unacceptable.

Error Prone Abbreviations and Symbols q. d every day mistaken for q.i.d when the period after the “q” is sloppily written to look like an “i” spell out “daily” q.o.d. every other day mistaken for q.d when the “o” is mistaken for a period spell out “every other day” (continued)

Error Prone Abbreviations and Symbols DC, D/C discharge, discontinue mistaken for “discontinue” when followed by medications prescribed at the time of discharge. Still used without any difficulties spell out “discontinue” or “discharge” >, < greater than, less than mistaken for each other spell out (continued)

Error Prone Abbreviations and Symbols AS, AD, AU left ear, right ear, both ears OS, OD, OU left eye, right eye, both eyes mistaken for each other spell out SC or SQ subcutaneous; ok to use SubQ mistaken for SL (sublingual), or “5 every”. spell out "subcutaneously“ or use Sub-Q (continued)

Sample Prescription

Videos of Taking a pt Hx  Taking a patient history for Medical Assistants By Del Mar (1 st 8 min)   Taking a patient history (8 min)   Clinical History Taking (20 min) 

Commonly Used Abbreviations (quiz material)  Hx (history), Sx (surgery or symptom, S/sx (sign and symptom), CC (chief complaint). SOAP (subjective, objective, assessment, plan)  q.d. (daily); q.o.d. (every other day); q.i.d. (four times a day), t.i.d. (three times a day), prn (as needed), ac (before meals), hs (hour of sleep or bedtime), po (by mouth), NPO (nothing by mouth)  AS (left ear), AD (right ear), AU (both ears), d/c or dc (discontinue or discharge).  SC or SQ (subcutaneous), IM (intramuscular)  /a (before), /p (after), /c (with), /s (without), VS or vs (vitals), tx (treatment or transfer), dx (diagnosis), pt (patient)  RTO (return to office), f/u (follow up)

Commonly Used Abbreviations (quiz material)  gtt (drip), mg (milligram), g (gram), kg (kilogram), L (liter)  WBC (white blood cells), RBC (red blood cells), HGB (hemoglobin), HCT (hematocrit), Na (sodium), K (potassium), BMP or CMP (basic or comprehensive metabolic panel), CBC (complete blood count), PT/INR (protime/international normalized ratio)  WNL (within normal limits), R/O (rule out)  CP (chest pain), HTN (hypertension), CHF (congestive heart failure), CABG (coronary artery bypass graft), CA (cancer), ETOH (alcohol), SOB (shortness of breath), HEENT (head, eyes, ears, nose, throat).  1400 (2pm), 1700 (5pm), 2100 (9pm)  L (left), R (right), B (bilateral).