ch 2 introduction to health records

where can health records be found

in a paper chart or electronic record (EHR)

what information is contained about the patient in their records

previous illnesses and treatments

continuing medical problems

history of family illnesses

current medications

SOAP

an acronym for the four different types of information documented by health care provides in a medical note

S= Subjective

what the patient says

O= Objective

what the tests reveal

A= Assessment

the analysis of the subjective and objective information; performed by the health care provider

P= Plan

the course of action for the patient

subjective

the problems that the patient states they have

those problems are translated into medical terms (makes for easier communication between health care providers)

general subjective terms

acute vs. chronic

abrupt

febrile vs. afebrile

malaise

progressive vs. exacerbation

symptoms

noncontributory

lethargic

genetic/ hereditary

objective

the data collected by the health care provider

this information includes data obtained from lab test or special images of the patients body

general objective terms

things that are seen: alert or oriented

things that are heard: auscultation or percussion

things that are felt: palpation

descriptions of what is observed: unremarkable or marked

assessment

this is the combination of the subjective and objective information

leads to a conclusion about the problem known as the diagnosis

If a single cause isn’t evident, a differential diagnosis—a list of the most likely causes—may be needed.

general assessment terms

impression

diagnosis

differential diagnosis

benign vs. malignant

degeneration

etiology vs. idiopathic

remission

recurrent

morbidity

mortality

prognosis

localized vs. systemic/ generalized

occult

pathogen

lesion

sequela

pending

plan

what the provider recommends to the patient regarding their current health status

can include medication, surgery, and/or further test, among other options

general plan terms

disposition

discharge

prophylaxis

palliative

observation

reassurance

supportive care

sterile

supine

laying flat on the back

prone

laying flat on the stomach

physician

a skilled health care provider who attended and graduated from medical school

pediatrician

a physician with special training in caring for children

surgeon

a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure

anesthesiologist

a physician with special training in pain sedation and pain control

physician assistant (PA)

a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training

nurse practitioner (NP)

a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician

emergency medical technician (EMT)

specially trained in the emergency care of a patient before and/or during transport to medical facility

speech therapist

specially trained in evaluating and treating problems with speech and/ or swallowing

occupational therapist

specially trained in evaluating and treating problems with performing daily activities at home, school, or work

physical therapist

specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury

respiratory therapist

specially trained in treating patients respiratory issues under the guidance of a health care provider

dietician

specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan

licensed practical nurse (LPN)

trained and certified to provide basic care to a patient

registered nurse (RN)

an advanced level nurse who has completed an associates or bachelors degree; often assists with patient care planning and patient education

medical assistant (MA)

trained to carry out basic administrative and clinical tasks under the guidance of a health care provider

pathologist

a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine

medical laboratory technician

trained in performing laboratory testing on bodily fluids

phlebotomist

trained in the removal of blood from the body for diagnostic or therapeutic purposes

radiologist

a physician specially trained in evaluating images of the body to diagnose illness or injury

radiology technician

trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider

ultrasonagrapher

trained in performing ultrasound imaging on a patient

pharmacist

trained and licensed in preparing and dispensing medicine

pharmacy technician

trained to assist a pharmacist with pharmacy related task

patient service coordinator

handles administrative tasks and coordinates patient care

medical transcriptionist

trained in converting the voice-recorded dictations of health care providers into text format

chief complaint

the main reason for the patients visit

history of present illness

the story of the patients problem

review of systems

description of individual body system in order to discover any symptoms not directly related to the main problem

past medical history

other significant past illnesses, like high blood pressure, asthma, or diabetes

past surgical history

any of the patients past surgeries

family history

any significant illnesses that run in the patients family

social history

a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

abbreviations for health care facility

pre-op, OR, PACU, post-op

ICU, CCU, SICU, PICU, NICU

ER,ED, and ECU

L&D

♂

male

♀

female

(B)

bilateral (both sides)

↑

increased

↓

decreased

common abbreviations on health records

VS like HR, RR, BP and T

Ht, Wt, BMI, and I/O

VS

vital signs

HR

heart rate

RR

respiratory rate

BP

blood pressure

T

temperature

Ht

height

Wt

weight

BMI

body mass index

I/O

input/ output

Dx

diagnosis

DDx

differential diagnosis

Tx

treatment

Rx

prescription

Hx

history

PMHx

past medical history

FHx

family history

H&P

history and physical

CC

chief complaint

HPI

history of present illness

ROS

review of systems

PE

physical exam

PCP

primary care provider

NKDA

no known drug allergies

PT

patient

y/o

years old

h/o

history of

f/u

follow up

PERRLA

pupils equal, round, and reactive to slight and accommodation

NOS

not otherwise specified

RRR

regular rate and rhythm

CTA

clear to auscultation

A&O

alert and oriented

NAD

no acute distress

PO

per os (by mouth)

IV

intravenous

SC

subcutaneous

CVL

central venous line

IM

intramuscular

PR

per rectum (anal)

NPO

nil per os (nothing by mouth)

prn

as needed

QID

four times a day

QD

Every day

AC

before meals