Health Care terms and language (Health care records) Medical Terminology

Objectives After studying this chapter, you should be able to: Know how to put your knowledge of medical terminology into use. Explain how this language is used in everyday communication about patients. Describe the common abbreviations, symbols, forms, and formats used in documenting the care of a patient.

Common Elements of the Medical Record 1-History and Physical (H&P) 2-Progress Notes

1- History and Physical (H&P) The history (Hx),documents subjective information from the patient’s personal statement about his or her medical history. A physical examination (PE), or a physical (Px) , obtain objective information, facts that can be seen or detected by doctor.

Common Abbreviations Used in the History and Physical MEANING CC chief complaint c/o complains of Dx diagnosis FH family history HPI, PI history of present illness, present illness PH, PMH past history, past medical history SH social history OH occupational history

Common Abbreviations Used in the History and Physical MEANING ROS, SR review of systems, systems review IMP impression P plan H&P history and physical Hx history PE, Px physical examination

2- Progress Notes After the initial H&P is recorded, progress notes are used to document the patient’s continued care. The SOAP method of documenting a patient’s progress is most common.

decision to proceed or to alter the plan strategy 2- Progress Notes S Subjective that which the patient describes O Objective observable information (e.g., test results and blood pressure readings) A Assessment patient’s progress and evaluation of the plan’s effectiveness P decision to proceed or to alter the plan strategy

Common Elements of the Medical Record – Notes Nurse’s Notes Physician’s Progress Notes

Common Elements of the Medical Record – Reports Consultation Reports Ancillary Reports Operative Report Anesthesiologist’s Report Diagnostic Reports Pathologist’s Report

COMMON DIAGNOSTIC TESTS AND PROCEDURES ABBREVIATION MEANING (x-ray) radiography (CT) computed tomography (MRA) Magnetic resonance angiography (MRI) magnetic resonance imaging (US) Sonography & ultrasound

Common Disease Terms ABBREVIATION MEANING acute sharp; intense, severe symptoms and a short course chronic develops slowly and persists over a period of time benign mild or noncancerous malignant harmful or cancerous localized limited to a definite area or part systemic relating to the whole body rather than to only a part symptom subjective evidence of disease that is perceived by the patient sign objective evidence of disease that can be seen or verified by an examiner

Medical Facilities Abbreviations MEANING CCU coronary (cardiac) care unit ECU emergency care unit ICU intensive care unit IP inpatient (a registered bed patient) OP outpatient

Patient Care Abbreviations MEANING CP chest pain L left R right pt patient SOB shortness of breath Tr &Tx treatment VS vital signs

ABBREVIATION MEANING T temperature P pulse R respiration BP blood pressure Ht height Wt weight

Units of Measure Abbreviation MEANING cc cubic centimeter cm centimeter g or gm gram kg kilogram L liter mg milligram mL or ml milliliter mm millimeter

Routes of Medication Administration Abbreviation DRUG FORM ROUTE OF ADMINISTRATION MEANING tablet (tab) oral by mouth capsule (cap) sublingual (SL) under the tongue suppository (suppos) Vaginal rectal [per rectum (PR)] inserted in the vagina inserted in the rectum parenteral by injection intradermal (ID) intramuscular (IM) intravenous (IV) subcutaneous (SC) within the skin within the muscle within the vein under the skin

Common Prescription Abbreviations and Symbols MEANING a.m. before noon p.m. after noon d day h hour q every q.d. every day wk week yr year b.i.d. twice a day t.i.d. three times a day q.i.d. four times a day NPO nothing by mouth