1. Medical Terminology A Programmed Learning Approach to the Language of Health Care, 2 nd Edition Chapter 2: Health Care Records

2. 2 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 Subjective information – history obtained from patient including his/her personal perceptions Objective information – physical facts and observations made by an examiner Objective information – physical facts and observations made by an examiner

3. 3 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

4. 4 History (Hx) Abbreviations CCChief Complaint Brief description of why patient is seeking care Brief description of why patient is seeking care c/ocomplains of Used in describing complaint Used in describing complaint PI or HPIPresent Illness or History of Present Illness Notation of duration and severity of complaint 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 Evidence of illness that the patient reports

5. 5 History (Hx) Abbreviations PH or PMHPast History or Past Medical History Notation of surgeries, injuries, physical defects, medications, allergies Notation of surgeries, injuries, physical defects, medications, allergies UCHDusual childhood diseases NKAno known allergies NKDA no known drug allergies (continued)

6. 6 History (Hx) Abbreviations FH Family History Notes about the state of health of immediate family members Notes about the state of health of immediate family members  Example: FH: father, age 58, mother, age 54, brother, age 32, all L&W A&W alive and well L&W living and well (continued)

7. 7 History (Hx) Abbreviations SHSocial History Recreational interests, hobbies, use of tobacco/drugs Recreational interests, hobbies, use of tobacco/drugs OHOccupational History Work habits that may involve work related risks Work habits that may involve work related risks ROS or SR Review of Systems or Systems Review Questions related to function of the body systems Questions related to function of the body systems (continued)

8. 8 Physical Exam (Px or PE)  Document of physical examination of a patient including notations of positive and negative findings Includes: results of diagnostic testing Includes: results of diagnostic testing Sign – objective evidence of disease Sign – objective evidence of disease

9. 9 Physical Exam Abbreviations HEENT head, eyes, ears, nose, and throat PERRLApupils equal, round, and reactive to light and accommodation NAD no acute distress WNL within normal limits

10. 10 History and Physical Impression (IMP) Diagnosis (Dx) Assessment (A) identification of a disease or condition after evaluation of all subjective and objective information 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 a differential diagnosis noted when one or more diagnoses are suspect; requires further testing to verify or eliminate each possibility

11. 11 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 and orders for medications, diagnostic tests, or therapies (continued)

12. 12 SOAP Progress Notes Progress notes made after the initial history and physical is recorded. The letters represent the order in which progress is noted: Ssubjective – that which the patient describes Oobjective – observable information, such as test results, blood pressure readings, etc. A assessment – progress and evaluation of the effectiveness of the plan P plan – decision to proceed or alter strategy

13. 13 Common Hospital Records  History and Physical  Physician’s orders  Diagnostic tests/laboratory reports  Nurse’s notes  Physician’s progress notes  Consultation report  Operative report  Pathology report  Anesthesiologist’s report

14. 14 Diagnostic Imaging Modalities IONIZING IMAGING  A process that changes the electrical charge of atoms with a possible effect on body cells; overexposure can have harmful side effects, e.g., cancer RADIOGRAPHY (X-RAY) RADIOGRAPHY (X-RAY) COMPUTED TOMOGRAPHY or COMPUTED AXIAL TOMOGRAPHY COMPUTED TOMOGRAPHY or COMPUTED AXIAL TOMOGRAPHY NUCLEAR MEDICINE IMAGING or RADIONUCLIDE ORGAN IMAGING NUCLEAR MEDICINE IMAGING or RADIONUCLIDE ORGAN IMAGING

15. 15 Diagnostic Imaging Modalities NONIONIZING IMAGING  an imaging process that presents no apparent risk MAGNETIC RESONANCE IMAGING MAGNETIC RESONANCE IMAGING SONOGRAPHY SONOGRAPHY (continued)

16. 16 Common Terms Related to Disease acute vs. chronic benign vs. malignant localized vs. systemic exacerbation vs. remission progressiverecurrentdegenerative

17. 17 Common Terms Related to Disease symptom (subjective) sign (objective) diagnosis (through knowing) syndrome (running together) prognosis (before knowing) etiology (study of cause) idiopathic (disease of individual) sequela (continued)

18. 18 Common Terms Related to Disease good vs. malaise febrile vs. afebrile markedequivocalnoncontributoryunremarkablemorbiditymortality (continued)

19. 19 Common Patient Care Abbreviations Use only those acceptable to workplace emergency facilityER, ECU place to recover after surgeryPAR, PACU registered bed patientIP care before surgerypreop, pre-op patientpt well-developed, well-nourishedWDWN bathroom privilegesBRP

20. 20 Common Patient Care Abbreviations shortness of breathSOB treatmentTx, Tr temperature, pulse, T, P, respiration, blood pressureR, BP = (vital signs) VS (vital signs) VS increase  decrease  degree or hour° pound or number sign# (continued)

21. 21 Error Prone Abbreviations and Symbols Medical errors caused by illegible writing and misinterpretations of abbreviations and symbols 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 abbreviations and symbols that are unacceptable.

22. 22 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” mistaken for q.i.d when the period after the “q” is sloppily written to look like an “i” spell out “daily” spell out “daily” q.o.d. every other day mistaken for q.d when the “o” is mistaken for a period mistaken for q.d when the “o” is mistaken for a period spell out “every other day” spell out “every other day” (continued)

23. 23 Error Prone Abbreviations and Symbols DC, D/C discharge, discontinue mistaken for “discontinue” when followed by medications prescribed at the time of discharge mistaken for “discontinue” when followed by medications prescribed at the time of discharge spell out “discontinue” or “discharge” spell out “discontinue” or “discharge” >,, < greater than, less than mistaken for each other mistaken for each other spell out “greater than” or “less than” spell out “greater than” or “less than” (continued)

24. 24 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 mistaken for each other spell out “left ear,” “right eye,” etc. spell out “left ear,” “right eye,” etc. SC or SQ subcutaneous mistaken for SL (sublingual) or “5 every” mistaken for SL (sublingual) or “5 every” spell out "subcutaneously“ or use sub-Q spell out "subcutaneously“ or use sub-Q (continued)

25. 25 Pharmaceutical Abbreviations and Symbols  Metric cc (cubic centimeter) cc (cubic centimeter) cm (centimeter) cm (centimeter) g or gm (gram) g or gm (gram) kg (kilogram) kg (kilogram) L (liter) L (liter) mg (milligram) mg (milligram) ml or mL (milliliter) Note: 1 cc = 1 mL ml or mL (milliliter) Note: 1 cc = 1 mL mm (millimeter) mm (millimeter) cu mm or mm 3 (cubic millimeter) cu mm or mm 3 (cubic millimeter)

26. 26 Pharmaceutical Abbreviations and Symbols  Apothecary fl oz (fluid ounce) fl oz (fluid ounce) gr (grain) gr (grain) gt (drop) gt (drop) gtt (drops) gtt (drops) dr (dram) dr (dram) oz (ounce) oz (ounce) lb or # (pound) lb or # (pound) qt (quart) qt (quart) (continued)

27. 27 Medication Administration - Drug Forms  Solid and Semisolid Forms Tablet (tab) Tablet (tab) Capsule (cap) Capsule (cap) Suppository (suppos) Suppository (suppos)  Liquid Forms Fluid Fluid Parenteral (ID, sub-Q, IM, IV) Parenteral (ID, sub-Q, IM, IV) Cream, lotion, ointment Cream, lotion, ointment Other delivery systems Other delivery systems  Transdermal  Implant

28. 28 Parenteral Drug Administration

29. 29 The Prescription  Physician’s written direction for dispensing or administering a medication for a patient  Must be written in a specific format  Rx  Symbol at beginning of prescription  Stands for recipe

30. 30 Drug Names Chemical name – assigned to drug at the time it is formulated Generic name – the official, nonproprietary name given a drug Trade or brand – the manufacturer's name for a drug

31. 31 Drug Names For example: Chemical name: 1-[3-(6,7-dihydro-1- ethyl-7-oxo-3-propyl-1H-pyrazolo[4,3- pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]- 4-methylpiperazine citrate Generic name: sildenafil Trade or Brand name: Viagra (continued)

32. 32 Sample Prescription

33. 33 Military Time

34. 34 Corrections  Careful clarification of an error when making an entry in a medical record is essential  Include: Date Date The abbreviation “corr” The abbreviation “corr” Initials of person making corrections Initials of person making corrections  Do not use correction fluid!

35. 35 Proper Correction of a Medical Record