Chapter 2: Intro. to Health Records

Lesion (LEE-shun) Assessment Word

Diseased Tissue

Nurse Practitioner (NP) (NIRS prak-TIH-shuh-ner) Health Professions-Health Providers

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

Transverse (tranz-VERS) Body Planes and Orientation-Body Planes

Divides the body from top to bottom.

Sagittal (SA-jih-tal) Body Planes and Orientation-Body Planes

Divides the body in slices right to left. Sagitta is Latin for arrow; think of this as dividing the body in half, as if someone shot an arrow through it.

Coronal (kah-ROH-nal) Body Planes and Orientation-Body Planes

Divides the body into slices from front to back. Corona is Latin for crown; this plane divides the body in half the top of the head down.

Impression (im-PREH-shun) Assessment Word

Another way of saying assessment.

Past Surgical History (PSH) Sections of a Health Record

Any of the patient's past surgeries.

Family History (FH) Sections of a Health Record

Any significant illnesses that fun in the patient's family.

ad lib Timing Abbreviations

As Desired

prn Timing Abbreviations

As Needed, from the Latin phrase per re nata, which means "as the need arises".

QHS Timing Abbreviations

At Night, from the Latin phrase quaque hora somni, which means "each night at the hour of sleep".

Emergency Department Note Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: ED Medical Staff Location: Emergency Department Purpose: Documents an emergency department visit. Format & Order: SOAP Unique Features: The A includes the emergency department course.

Admission Summary Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Hospital Medical Professional Location: Hospital Purpose: Documents admission of a patient to the hospital. Format & Order: SO A/P Unique Features: S, O= Very Thorough A= Differential Diagnosis P= Further Testing and Care A+P= Problem- Based Approach

Prescription Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Medical Professional Location: Purpose: Provides directions for a medication. Format & Order: P Unique Features: 1. Medicine's Name 2. Instructions for Patient 3. How much medicine should be given. 4. Refills, if any. 5. Health care professional's signature and whether generic substitution is allowed.

Discharge Summary Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Medical Professional Location: Hospital Purpose: Describes when and why the patient was admitted; documents a longer stay. Format & Order: ASOP Unique Features: Starts with A

Daily Hospital Note/ Progress Note Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Medical Professional Location: Inpatient Health Care Facility Purpose: Documents Daily Hospital Visit Format & Order: SO A/P Unique Features: S-Focuses on how patient's condition has changed since the previous note. A-Sometimes includes a differential diagnosis.

Clinical Note Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Medical professional Location: Clinic Purpose: Documents a Visit Format & Order: SOAP Unique Features: New Patient: Includes more history, separate form. Repeat Patient: Streamlined note.

Pathology Report Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Pathologist Location: Purpose: Provides reasons for test, what was seen on the test, and an assessment. Format & Order: SOA Unique Features:

Consult note Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Physician; Usually a Specialist Location: Clinic or Hospital Purpose: Provides an expert opinion on a more challenging problem. Format & Order: SOAP Unique Features: Can be in the form of a letter to the PCP.

Radiology Report Author: ? Location: ? Purpose: ? Format & Order: ? Unique Features: ? Summary of Health Record Notes

Author: Radiologist Location: Purpose: Explains reason for image, how image was performed, what was seen on image, radiologist's assessment; sometimes a recommendation. Format & Order: SOA Unique Features: Usually includes only S, O, and A, but may include a P if it recommends that further studies should be performed.

Operative Report Author: ? Location: Purpose: ? Format & Order: ? Unique Features: Summary of Health Record Notes

Author: Surgeon Location: Purpose: Documents a surgery in detail Format & Order: ASOP Unique Features:

NEC Abbreviations Used for Symptoms or Exam Findings

Not Elsewhere Classified NOTE: NOS and NEC are catch-alls for diagnosis that don't quite fit any specific cause (for example, "rash NOS")

NOS Abbreviations Used for Symptoms or Exam Findings

Not Otherwise Specified

Malaise (mah-LAYZ) Subjective Word

Not feeling well.

Noncontributory (NON-kon-TRIB-yoo-TOH-ree) Subjective Word

Not related to this specific problem.

Unilateral (YOO-nih-LA-ter-al) Body Planes and Orientation-Opposites

One Side

OR Health Care Facility Abbreviations

Operating Room

Contralateral (KON-trah-LA-ter-al) Body Planes and Orientation-Opposites

Opposite Side

Past Medical History (PMH) Sections of a Health Record

Other significant past illnesses, like high blood pressure, asthema, or diabetes.

Lateral (La-ter-al) Body Planes and Orientation-Opposites

Out to the side.

What type of data would one see in the SUBJECTIVE part of SOAP?

PMH -Past Medical History (ie: personal & family medical history) Description of the patient's problem in their own words.

PMHx Health Care Facility Abbreviations

Past Medical History

Pt Health Care Facility Abbreviations

Patient

PICU Health Care Facility Abbreviations

Pediatric Intensive Care Unit

PICC Abbreviations Associated with Orders and Administering Medicine

Peripherally Inserted Central Catheter

Emergency Medical Technician (EMT) (eh-MIR-jen-see MEh-dih-kal tek-NIH-shun) Health Professions-Health Providers

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

Respiratory Therapist (reh-prah-TOR-ee THEH-rah-pist) Health Professions-Health Providers

Specially trained in treating patient's respiratory issues under the guidance of a health care provider.

Localized (LOH-kah-LAIZD) Assessment Word

Stays in a certain part of the body.

SC Abbreviations Associated with Orders and Administering Medicine

Subcutaneous (under the skin)

SICU Health Care Facility Abbreviations

Surgical Intensive Care Unit

T Health Care Facility Abbreviations

Temperature

Dorsal/Posterior (DOR-sal, pohs-TEER-ee-or) Body Planes and Orientation-Opposites

The Back A dorsal fin on a shark is on its back.

Etiology (ee-tee-AW-loh-jee) Assessment Word

The Cause

Ventral/Antral/Anterior (VEN-tral, AN-tral, an-TIH-ree-or) Body Planes and Orientation-Opposites

The Front The word ventral means "stomach".

Prognosis (prawg-NOH-sis) Assessment Word

The chances for things getting better or worse.

Cheif Complaint (CC) Sections of a Health Record

The main reason for the patient's visit.

Pathogen (PATH-oh-jin) Assessment Word

The organism that causes the problem.

Palmer (PAL-mar) Body Planes and Orientation-Opposites

The palm of the hand.

Morbidity (mor-BID-ih-tee) Assessment Word

The risk for being sick.

Mortality (mor-TA-lih-tee) Assessment Word

The risk for dying.

Licensed Practical Nurse (LPN) (LAI-senzd PRAK-tih-kal NIRS) Licensed Vocational Nurse (LVN) (LAI-senzd voh-KAY-shun-al NIRS) Health Professions-Health Providers

Trained and certified to provide basic care to a patient.

Pharmacist (FAR-mah-sist) Health Professions-Pharmacy

Trained and licensed in preparing and dispensing medicine.

Medical Transcriptionist (MEH-dih-kal tran-SKRIP-shun-ist) Health Professions-Clinical Support

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

Medical Laboratory Technician (meh-DIH-kal LAH-broh-tor-ee tek-NIH-shun) Health Professions-Labratory and Pathology

Trained in performing laboratory testing on bodily fluids.

Ultrasonographer (ul-trah-saw-NAW-grah-fir) Health Professions-Radiology

Trained in performing ultrasound imaging on a patient.

Phlebotomist (fleh-BOH-tow-mist) Health Professions-Labratory and Pathology

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

Pharmacy Technician (FAR-mah-see tek-NIH-shun) Health Professions-Radiology

Trained to assist a pharmacist with pharmacy-related tasks.

Medical Assistant (MEH-dih-kal ah-SIS-tant) Health Professions-Health Providers

Trained to carry out basic administrative and clinical tasks under the guidance of a healthcare provider.

Radiology Technician (ray-dee-AW-loh-jee tek-NIH-shun) Health Professions-Radiology

Trained to perform radiologic testing or administer radiation therapy under the direction of a healthcare provider.

Palliative (PA-lee-ah-tiv) Plan Word

Treating the symptoms, but not actually getting rid of the cause.

Tx Health Care Facility Abbreviations

Treatment

BID Timing Abbreviations

Twice Daily, from the Latin phrase bis in die, which means "two in a day".

VS Abbreviations Common On Health Records

Vital Signs

Pending (PEN-ding) Assessment Word

Waiting for.

Observation (OB-zer-VEY-shun) Plan Word

Watch, keep an eye on.

Wt Health Care Facility Abbreviations

Weight

WDWN Abbreviations Used for Symptoms or Exam Findings

Well Developed, Well Nourished (The patient is growing or has grown appropriately and does not appear to be malnourished)

Disposition (dis-poh-ZIH-shun) Plan Word

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

Diagnosis (DAI-ag-NOH-sis) Assessment Word

What the health care professional thinks the patient has.

SOB Abbreviations Used for Symptoms or Exam Findings

While it may mean something outside of medicine, here, it means shortness of breath. NOTE: Because of the negative nonmedical meaning, it has been suggested that SOB should be replaced by other abbreviations like SOA (shortness of air).

WNL Abbreviations Used for Symptoms or Exam Findings

Within Normal Limits

NPO Abbreviations Associated with Orders and Administering Medicine

nil per os (nothing by mouth)

PO Abbreviations Associated with Orders and Administering Medicine

per os (by mouth)

PR Abbreviations Associated with Orders and Administering Medicine

per rectum (anal)

Sterile (STEH-ril) Plan Word

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

FHx Health Care Facility Abbreviations

Family History

Distal (DIH-stal) Body Planes and Orientation-Opposites

Farther away from the center. Distal and distant come from the same word and mean for.

f/u Health Care Facility Abbreviations

Follow Up

QID* Timing Abbreviations

Four Times Daily, fromt he Latin phrase quarter in die, which means "four in a day".

Up-Arrow Symbols

Increased

Sig Abbreviations Associated with Orders and Administering Medicine

Instructions short for signa, from Latin, for "label"

I/O Health Care Facility Abbreviations

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

ICU Health Care Facility Abbreviations

Intensive Care Unit

IM Abbreviations Associated with Orders and Administering Medicine

Intramuscular

IV Abbreviations Associated with Orders and Administering Medicine

Intravenous

Chronic (KRAH-nik) Subjective Word

It has been going on for a while now.

Exacerbation (ek-SAS-er-BAY-shun) Subjective Word

It is getting worse.

Acute (ah-KYOOT) Subjective Word

It just started recently or is a sharp, severe symptom.

Genetic/Hereditary (jih-NEH-tik, hah-REH-dih-TEH-ree) Subjective Word

It runs in the family.

L&D Health Care Facility Abbreviations

Labor and Delivery

(L)

Left

What side of the body does the right hemisphere control?

Left Side

Medial (MEE-dee-al) Body Planes and Orientation-Opposites

Like the median of a highway.

Discharge (DIS-charj) Plan Word

Literally to unload; it has two meanings: 1. To send home (to unload the patient from the health care setting to home). 2. Fluid coming out of a part of the body (your body unloading a fluid).

Supine (SOO-pain) Body Planes and Orientation-Opposites

Lying down on back.

Prone (PROHN) Body Planes and Orientation-Opposites

Lying down on the belly.

Progressive (proh-GREH-siv) Subjective Word

More and more each day.

NICU Health Care Facility Abbreviations

Neonatal Intensive Care Unit

NAD Abbreviations Used for Symptoms or Exam Findings

No Acute Distress (The patient does not display any intense symptoms)

NKDA Health Care Facility Abbreviations

No Known Drug Allergies

Idiopathic (ih-dee-oh-PA-thik) Assessment Word

No known specific cause; it just happens.

Q Timing Abbreviations

Every x, example Q4hr would mean every 4 hours or Q3 days would be every 3 days.

PERRLA Abbreviations Used for Symptoms or Exam Findings

Pupils are equal, round, and reactive to light and accommodation.

Lethargic (lah-THAR-jik) Subjective Word

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

Differential Diagnosis (dih-fer-EN-shal DAI-ag-NOH-sis) Assessment Word

A list of conditions the patient mas have based on the symptoms exhibited and the results of the exam.

Physician Assistant (PA) (fuh-ZIH-shun-ah-SIS-tant) Health Professions-Health Providers

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

Caudal (KOW-dal) Body Planes and Orientation-Opposites

Toward the bottom. from Latin, for tail.

Cranial (KRAY-nee-al) Body Planes and Orientation-Opposites

Toward the top.

Superior (soo-PIH-ree-or) Body Planes and Orientation-Opposites

Above

CC Health Care Facility Abbreviations

Chief Complaint (The main reason for the visit)

CTA Abbreviations Used for Symptoms or Exam Findings

Clear to Auscultation (Description of normal-sounding lungs)

QD* Timing Abbreviations

Daily, from the Latin phrase quaque die, which means "each day".

Malignant (mah-LIG-nant) Assessment Word

Dangerous; A Problem

Down-Arrow Symbols

Decreased

Review of Symptoms (ROS) Sections of a Health Record

Description of individual body systems in order to discover any symptoms not directly related to the main problem.

Dx Health Care Facility Abbreviations

Diagnosis

DDx Health Care Facility Abbreviations

Differential Diagnosis

Surgeon (SIR-jen) Health Professions-Health Providers

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

Radiologist (ray-dee-AW-loh-jist) Health Professions-Radiology

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

Pathologist (pah-THAW-loh-jist) Health Professions-Labratory and Pathology

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

Pediatrician (PEE-dee-ah) Health Professions-Health Providers

A physician with special training in caring for children.

Anesthesiologist (AN-ehs-THEE-zee-AW-loh-jist) Health Professions-Health Providers

A physician with special training in pain sedation and pain control.

Sequelae (seh-KWEL-ah) Assessment Word

A problem resulting from a disease or injury.

Social History (SH) Sections of a Health Record

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

Physician (fuh-ZIH-shun) Health Professions-Health Providers

A skilled healthcare provider who attended and graduated medical school. There are two types who practice in America: medical doctor (MD) and doctor of osteopathy (DO).

PC Timing Abbreviations

After Meals, from the Latin phrase post cibum, which means "after food".

Post-Op Health Care Facility Abbreviations

After Surgery

A&O Abbreviations Used for Symptoms or Exam Findings

Alert and Oriented (The patient can answer questions and is aware of what's going on)

Abrupt (ah-BRUPT) Subjective Word

All of a sudden.

Systemic/Generalized (sih-STEM-ik, jen-er-ah-LAIZD) Assessment Word

All over the body (or most of it).

Registered Nurse (RN) (REH-jis-terd NIRS) Health Professions-Health Providers

An advanced level nurse who has completed an associate's or bachelor's degree; often assists with patient care planning and patient education.

AC Timing Abbreviations

Before Meals, from the Latin phrase ante cibum, which means "before food".

Pre-Op Health Care Facility Abbreviations

Before Surgery

Inferior (in-FIH-ree-or) Body Planes and Orientation-Opposites

Below

(B)

Bilateral (Both Sides)

BP Health Care Facility Abbreviations

Blood Pressure

BMI Health Care Facility Abbreviations

Body Mass Index (Measurement of body fat based on height and weight)

Bilateral (BAI-LA-ter-al) Body Planes and Orientation-Opposites

Both Sides

CV Abbreviations Used for Symptoms or Exam Findings

Cardiovascular

CVL Abbreviations Associated with Orders and Administering Medicine

Central Venous Line

Proximal (PRAWK-sih-mal) Body Planes and Orientation-Opposites

Closer in to the center. Proximal and approximate come from the same word and mean close.

CCU Health Care Facility Abbreviations

Coronary Care Unit

ECU Health Care Facility Abbreviations

Emergency Care Unit

ED Health Care Facility Abbreviations

Emergency Department

ER Health Care Facility Abbreviations

Emergency Room

Patient Service Coordinator (PAY-shent SIR-vis coh-OR-dih-nay-tor) Health Professions-Clinical Support

Handles administrative tasks and coordinates patient care.

HEENT Abbreviations Used for Symptoms or Exam Findings

Head, Eyes, Ears, Nose, and Throat

HR Health Care Facility Abbreviations

Heart Rate

Ht Health Care Facility Abbreviations

Height

Occult (ah-KULT) Assessment Word

Hidden

Hx Health Care Facility Abbreviations

History

h/o Health Care Facility Abbreviations

History Of

H&P Health Care Facility Abbreviations

History and Physical

HPI Health Care Facility Abbreviations

History of Present Illness (The story of the symptoms)

PE Health Care Facility Abbreviations

Physical Exam

PACU Health Care Facility Abbreviations

Post-Anesthesia Care Unit

Rx Health Care Facility Abbreviations

Prescription

Prophylaxis (PROH-fuh-LAK-sis) Plan Word

Preventative Treatment

PCP Health Care Facility Abbreviations

Primary Care Provider

RRR Abbreviations Used for Symptoms or Exam Findings

Regular Rate and Rhythm (Description of a normal heart on exam)

RR Health Care Facility Abbreviations

Respiratory Rate

ROS Health Care Facility Abbreviations

Review of systems (Anything else not directly related to the chief complaint)

(R)

Right

What side of the body does the left hemisphere control?

Right Side

What does each letter in SOAP stand for?

S = Subjective (patient's complaints) O = Objective (results of physical exam, lab tests, ABGs, chest radiograph, etc.) A = Assessment (What is the problem?) P = Plan (How is the problem to be treated?)

What are the 4 colors that help differentiate each section of SOAP?

S: Subjective- Blue O: Objective- Red A: Assessment- Yellow P: Plan- Green (Note: sometimes assessment and plan run together; these instances appear in light green.)

Benign (beh-NAIN) Assessment Word

Safe

Ipsilateral (IP-sih-LA-ter-al) Body Planes and Orientation-Opposites

Same Side

Symptom (SIM-tom) Subjective Word

Something a patient feels.

Physical Therapist (FIH-zih-kal THEH-rah-pist) Health Professions-Health Providers

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

Occupational Therapist (aw-kyoo-PAY-shuh-nal THEH-rah-pist) Health Professions-Health Providers

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

Speech Therapist (SPEECH THAH-rah-pist) Health Professions-Health Providers

Specially trained in evaluating and treating problems with speech and/or swallowing.

Dietician (dai-ah-TIH-shun) Health Professions-Health Providers

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

Plantar (PLAN-tar) Body Planes and Orientation-Opposites

The sole of the foot.

History of Present Illness (HPI) Sections of a Health Record

The story of the patient's problem.

Dorsum (DOR-sum) Body Planes and Orientation-Opposites

The top of the hand or foot.

TID Timing Abbreviations

Three Times Daily, from the Latin phrase ter in die, which means "three in a day".

Degeneration (dee-jen-er-AY-shun) Assessment Word

To be getting worse.

Remission (reh-MIH-shun) Assessment Word

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

Febrile (FEH-brail) Subjective Word

To have a fever.

Recurrent (ree-KUR-ent) Assessment Word

To have again.

Afebrile (AY-FEH-brail) Subjective Word

To not have a fever.

Reassurance (ree-ah-SHUR-ants) Plan Word

To tell the patient that the problem is not serious or dangerous.

Supportive Care (suh-POR-tive kehr) Plan Word

To treat the symptoms and make the patient feel better.

y/o Health Care Facility Abbreviations

Years Old