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Chapter 4. The Medical Record. History and Physical H & P. Figure 4.1 page 58. Document of medical history and findings from physical examination Includes: Subjective information — History obtained from patient including his/her personal perceptions

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history and physical h p
History and Physical H & P

Figure 4.1 page 58

  • 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
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
History (Hx) Abbreviations

CC Chief Complaint orc/o complains ofBrief description of why patient is seeking care

PI or HPI Present Illness/History of Present IllnessNotation of duration and severity of complaintHow bad is it? How long have they had it?

Sx symptomEvidence of illness that the patient reports

history hx abbreviations1
History (Hx) Abbreviations

(continued)

PH, PMH Past History, Past Medical HistoryNotation of surgeries, injuries, physical defects, medications, allergies

UCHD usual childhood diseases

NKA no known allergies

NKDA no known drug allergies

history hx abbreviations2
History (Hx) Abbreviations

(continued)

FH Family HistoryNotes 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

history hx abbreviations3
History (Hx) Abbreviations

(continued)

SH Social Historyrecreational interests, hobbies, use of tobacco/drugs

OH Occupational Historywork habits that may involve work related risks

ROS or SR Review of Systems, Systems Reviewquestions related to function of the body systems

HEENT head, eyes, ears, nose, throat

physical exam px or pe
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
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
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 physical1
History and Physical

(continued)

PLAN,RECOMMENDATION, orDISPOSITION

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

problem oriented medical record pomr
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
soap notes
SOAP 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
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
common patient care abbreviations
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

patient pt

well developed, well nourished WDWN

bathroom privileges BRP

common patient care abbreviations1
Common Patient Care Abbreviations

(continued)

difficulty breathing SOB

treatment 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
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 symbols1
Error Prone Abbreviations and Symbols

(continued)

q. d every daymistaken 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 daymistaken for q.d when the “o” is mistaken for a period

spell out “every other day”

error prone abbreviations and symbols2
Error Prone Abbreviations and Symbols

(continued)

DC, D/C discharge, discontinuemistaken for “discontinue” when followed by medications prescribed at the time of discharge

spell out “discontinue” or “discharge”

>, < greater than, less thanmistaken for each other

spell out

error prone abbreviations and symbols3
Error Prone Abbreviations and Symbols

(continued)

AS, AD, AU left ear, right ear, both earsOS, OD, OU left eye, right eye, both eyesmistaken for each other

spell out

SC or SQ subcutaneousmistaken for SL (sublingual), or “5 every”.

spell out "subcutaneously“ or use Sub-Q

diagnostic imaging modalities
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 modalities1
Diagnostic Imaging Modalities

(continued)

NON-IONIZING IMAGING a process that presents no apparent risk

  • MAGNETIC RESONANCE IMAGING
  • SONOGRAPHY
common terms related to disease
Common Terms Related to Disease

acute vs chronic

benign vs malignant

localized vs systemic

exacerbation vs remission

progressive

recurrent

degenerative

common terms related to disease1
Common Terms Related to Disease

(continued)

symptom (subjective)

sign (objective)

diagnosis (through knowing)

syndrome (running together)

prognosis (before knowing)

etiology (study of cause)

idiopathic (disease of individual)

sequela

common terms related to disease2
Common Terms Related to Disease

(continued)

good vs malaise

febrile vs afebrile

gross

marked

equivocal

noncontributory

unremarkable

morbidity

mortality

pharmaceutical abbreviations and symbols
Pharmaceutical Abbreviations and Symbols
  • Metric
    • cc (cubic centimeter)
    • cm (centimeter)
    • g or gm (gram)
    • kg (kilogram)
    • L (liter)
    • mg (milligram)
    • ml, ML (milliliter) Note: 1 cc = 1 mL
    • mm (millimeter)
    • cu, mm (cubic millimeter)
pharmaceutical abbreviations and symbols1
Pharmaceutical Abbreviations and Symbols

(continued)

  • Apothecary
    • fl oz (fluid ounce)
    • gr (grain)
    • gt (drop)
    • gtt (drops)
    • dr (dram)
    • oz (ounce)
    • lb or # (pound)
    • qt (quart)
medication administration drug forms
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
the prescription
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
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 names1
Drug Names

(continued)

For example:

Chemical name: 1-[[3-(6,7-dihydro-1-methyl-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

corrections
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!