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

2. 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.

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

5. 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.

6. 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

7. 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

8. 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.

9. 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

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

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

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

13. 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

14. 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

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

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

17. 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

18. 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

19. 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