ALH 111 - Chapter 2: Introduction to Health Records

Subjective

Subject to how the pt experiences and personally describes their problem. Includes personal and family medical history. Duration of the problem, quality of the problem, exacerbating/relieving factors. Current medications and allergies.

Acute

it just started recently or is a sharp, severe symptom

Chronic

it has been going on for a while now

Exacerbation

it is getting worse

Abrupt

all of a sudden

Febrile

fever

Afebrile

no fever

malaise

not feeling well

progressive

more and more each day

symptom

something a pt feels

noncontributory

not related to this specific problem

lethargic

a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick

genetic/hereditary

it runs in the family

Objective

How the pt looks, sounds, feels, smells. Physical exam, lab findings, imaging studies.

Alert

able to answer questions; responsive; interactive

Oriented

being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented x 3"

Marked

it really stands out

Unremarkable

another way of saying normal

Auscultation

to listen

Percussion

to hit something and listen to the resulting sound or feel for the resulting vibration

Palpation

to feel

Assessment

Diagnosis, identification of a problem, or list of possibilities for the diagnosis (differential diagnosis)

Impression

another way of saying assessment

Diagnosis

what the healthcare professional thinks the patient has

Differential diagnosis

a list of conditions the patient may have based on the symptoms exhibited and the results of the exam

Benign

safe

Malignant

dangerous; a problem

Degeneration

to be getting worse

Etiology

the cause

Remission

to get better or improve; most often used when discussing cancer; remission does not mean cure

Idiopathic

no known specific cause; it just happens

Localized

stays in a certain part of the body

Systemic/generalized

all over the body (or most of it)

Morbidity

the risk for being sick

Mortality

the risk for dying

Prognosis

the chances for things getting better or worse

Occult

hidden

Pathogen

an organism that causes disease

Lesion

diseased tissue

Recurrent

to have again

Sequelae

a problem resulting from a disease or injury

Pending

waiting for

Plan

Recommendations for what to do about the pt's health status. Medicine, home remedies, help from another provider, surgery, waiting to see if problem improves, data collection.

Disposition

what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed)

Discharge

1. to send home

2. fluid coming out of a part of the body

Prophylaxis

preventive treatment

Palliative

treating the symptoms, but not actually getting rid of the cause

Observation

watch, keep an eye on

Reassurance

to tell the patient that the problem is not serious or dangerous

Supportive care

to treat the symptoms and make the patient feel better

Sterile

extremely clean, germ-free conditions; especially important during medical procedures and surgery

Proximal

closer to the center

Distal

farther from the center

Lateral

out to the side

Medial

toward the middle

Ventral/anterior/antral

front

Dorsal/posterior

the back

Cranial

toward the top

Caudal

toward the bottom

Superior

above

Inferior

below

Prone

lying on the belly (face down)

Supine

lying on the back

Contralateral

opposite side

Ipsilateral

same side

Unilateral

one side

Bilateral

both sides

Dorsum

the top of the hand or foot

Plantar

sole of foot

Palmar

palm of the hand

Sagittal plane

divides body into left and right

Coronal plane

divides the body into slices from front to back

Transverse plane

divides the body into superior and inferior parts

Chief complaint

the main reason for the patient's visit

History of present illness

the story of the patient's problem

Review of systems

description of individual body systems 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 patient's past surgeries

Family history

any significant illnesses that run in the patient's family

Social history

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

(R)

right

(L)

left

(B)

bilateral

VS

vital signs

T

temperature

BP

blood pressure

HR

heart rate

RR

respiratory rate

Ht

height

Wt

weight

BMI

body mass index

I/O

intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)

Dx

diagnosis

DDx

differential diagnosis

Tx

treatment

Rx

prescription

H&P

history and physical

Hx

history

CC

chief complaint

HPI

history of present illness