SA Class 1: Introduction

Review of systems

What does ROS stand for?

Subjective

The HPI and ROS yield what category of information?

Objective

The physical exam yields what category of information?

Physical exam

If a physician told you a patient’s abdomen was nontender or the patient’s skin was pale, where would you document this information?

HPI

Which section of the EMR focuses directly on the chief complaint?

HR, RR, BP, temp, SpO2

What are the five vital signs?

CABG

Name an example of something you’d write in the PSHx portion of the chart.

Smokes 1 ppd

Name an example of something you may write in the SHx portion of the chart.

Mother has HTN diagnosed at age 44

Name an example of something you may write in the FHx portion of the chart.

Appendectomy

Medical term for appendix removal

Cholecystectomy

Medical term for gallbladder removal

hysterectomy

Medical term for uterus removal

tonsillectomy

Medical term for tonsil removal