Medical Records

medical record contains

hospital and clinic records, history and physical (H&P), provider notes, lab and test reports

HIPAA

Health Insurance Portability and Accountability Act to standardized access to patient’s information

8 components of medical record

chief complaint (CC), history of present illness (HPI), past medical history (PMH) with surgical, social, family, review of systems (ROS), physical with vital signs (VS) and inspection, palpation, percussion, auscultation (IPPA), lab and imaging, diagnosis, disposition (treatment and plan)

history and physical (H&P)

chief complaint (CC), history of present illness (HPI), symptom, sign

chief complaint (CC)

subjective and direct quote

history of present illness (HPI)

chronological subjective complaints starting with “this is a blank year old who presents with chief complaint of”

uses OPQRST or OLD CARTS

OPQRST

onset, provocation/palliation, quality, region and radiation, severity, time

OLD CARTS

onset, location, duration, character, aggravating/alleviating, radiation, time, severity

past medical history (PMH)

medical, surgical, medications, allergies, vaccination, social, family

symptom

subjective experience

sign

objective physical finding

review of systems (ROS)

subjective review of systems and symptoms associated based on current CC/HPI

physical examination

objective data (vitals, IPPA)

vital signs

objective measurements of temperature, heart rate, blood pressure, respiratory rate, oxygenation

where can you measure temperature with thermometer?

under tongue, axillary, tympanic, rectum

normal adult temperature

98.6F, 37C

hypothermia

low temperature

normothermia

37C

hyperthermia

high temperature

thermoregulation

maintaining body temperature

heart rate unit

beats per minute

heart rate can be measured in what 4 ways

pulse oximeter, electrocardiogram, pulse sites, auscultation with stethoscope for apical pulse

when documenting heart rate state

regular or irregular

8 pulse sites

temporal, femoral, popliteal, posterior tibial, carotid, brachial, radial, dorsalis pedis

pulse measurements by hand must document

strength of pulses bilaterally with 0 absent, 1+ weak, 2+ normal, 3+ bounding

normal adult heart rate

60-100 beats per minute

tachycardia

fast heart rate

bradycardia

slow heart rate

arrhythmia/dysrhythmia

abnormal heart rhythm

blood pressure

force on arterial walls by blood

blood pressure reported as

systolic blood pressure/diastolic blood pressure

blood pressure unit

millimeters of mercury (mmHg)

what is blood pressure measured with

blood pressure cuff (sphygmomanometer)

sphygmomanometer

blood pressure cuff

where is blood pressure taken

brachial site

systolic BP

force on arterial walls during systole (contraction)

diastolic BP

force on arterial walls during diastole (relaxation)

normal systolic BP

100-140 mmHg

normal diastolic BP

60-90 mmHg

MAP

mean arterial pressure

normal MAP

greater than 65

hypotension

low blood pressure

hypertension

high blood pressure

normotensive

normal blood pressure

respiratory rate unit

breaths per minute

normal respiratory rate

12-20 breaths per minute

-pnea, spir/o

breathing

tachypneic/tachypnea

rapid breathing

bradypneic/bradypnea

slow breathing

hypoventilation

too little ventilation of lungs

hyperventilation

too much ventilation of lungs

apnea

stop breathing

oxygenation saturation unit

percentage out of 100

oxygenation saturation measured with

pulse oximeter

normal adult oxygenation level

greater than 94%

exception to 94% oxygenation level

chronic lung diseases

ox/o, -oxia

oxygen

hypoxia

low oxygen in tissues

hypoxemia

low oxygen in blood

anoxia

without oxygen

IPPA

inspection, palpation, percussion, auscultation

inspection

examine body throughout visit noticing appearance, mental status, posture, color, deformities, body language, gait

palpation

use pads of fingers to touch and examine location of structures/masses, size, texture, temperature, tenderness

percussion

use fingers to tap and assess for presence of fluid or air based on sound

auscultation

listen to sounds of heart, blood vessels, lungs, abdomen, bowels using stethoscope

right lung has how many lobes

3

left lung has how many lobes

2

exception to IPPA

gastrointestinal system; inspect then auscultation then percussion then palpate

enophthalmos

eye sinking

exophthalmos

eye protrude

acute

sudden onset and brief course

chronic

persistent disease or illness

etiology

cause

exacerbation

increase in severity

inflammation

cytologic and chemical changes in tissue

lesion

pathological change in tissue

necrosis

cell or tissue death

prognosis

predicted outcome

cytology

study of cells

histology

study of cells and tissues

abdomin/o

abdomen

acr/o

extremities

aden/o

gland

brachi/o

arm

cervic/o

neck

cyt/o

cell

epitheli/o

epithelium

fibr/o

fiber

hemat/o

blood

hist/o

tissue

hydr/o

water

leiomy/o

smooth

lip/o

fat

lumb/o

lumbar

morph/o

form, shape

my/o

muscle

necr/o

death

neur/o

nerve

nucle/o

nucleus

oste/o

bone