Medical Terminology

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

History and Physical (H&P) Document of medical history and findings from physical examination Includes: Subjective information – historyobtained from patient including his/her personal perceptions Objective information – physicalfacts 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 Brief description of why patient is seeking care c/o complains of Used in describing complaint PIorHPI Present Illness or 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 or PMH Past History or 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 FH Family History 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)

History (Hx) Abbreviations SH Social History Recreational interests, hobbies, use of tobacco/drugs OH Occupational History Work habits that may involve work related risks ROSorSR Review of Systems or Systems Review Questions related to function of the body systems (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, and throat PERRLA pupils equal, round, and reactive to light and accommodation NAD no acute distress 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, orDISPOSITION 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)

SOAP Progress Notes Progress notes made after the initial history and physical is recorded. The letters represent the order in which progress is noted: S subjective – that which the patient describes O objective – 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

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

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) COMPUTED TOMOGRAPHY or COMPUTED AXIAL TOMOGRAPHY NUCLEAR MEDICINE IMAGING or RADIONUCLIDE ORGAN IMAGING

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

Common Terms Related to Disease acute vs. chronic benign vs. malignant localized vs. systemic exacerbation vs. remission progressive recurrent degenerative

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)

Common Terms Related to Disease good vs. malaise febrile vs. afebrile marked equivocal noncontributory unremarkable morbidity mortality (continued)

Common Patient Care Abbreviations Use only those acceptable to workplace emergency facility ER, ECU place to recover after surgery PAR, PACU registered bed patient IP care before surgery preop, pre-op patient pt well-developed, well-nourished WDWN bathroom privileges BRP

Common Patient Care Abbreviations shortness of breath SOB treatment Tx, Tr temperature, pulse, T, P, respiration, blood pressure R, BP = (vital signs) VS increase  decrease  degree or hour ° pound or number sign # (continued)

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.

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 spell out “discontinue” or “discharge” >, < greater than, less than mistaken for each other spell out “greater than” or “less than” (continued)

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

Pharmaceutical Abbreviations and Symbols Metric cc (cubic centimeter) cm (centimeter) g or gm (gram) kg (kilogram) L (liter) mg (milligram) ml or mL (milliliter) Note: 1 cc = 1 mL mm (millimeter) cu mm or mm3 (cubic millimeter)

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

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

Parenteral Drug Administration

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

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

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)

Sample Prescription

Military Time

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

Proper Correction of a Medical Record

Medical Terminology