Chapter two - Medical Histories Flashcards
CC: Chief Complaint
Reason why the patient is seeing you
HPI: Hx of Present Illness
Amplifies the Chief Complaint, describes how each symptom developed, gives the seven attributes of every symptom.
PMHx: Past Medical History
Surgical, past medical, psychiatric, childhood illnesses.
SHx: Social History
Family of origin, current household, personal interests, and lifestyle. Illicit drug use and alcohol should also be noted. Religion and marital status
ROS: Review of Systems
Documents presence or absence of common symptoms related to each major body system. Ask closed ended questions about major body systems.
Alg: Allergies
Allergies and reactions
Immune: Immunizations
vaccines and dates. Tetanus included.
PE: Physical Exam
vitals, ROM, eyes, nose, ears, heart, stomach. MA can do this.
Labs
Blood work, x-rays, EKG,
Meds: Medications
Current Meds patient is taking
A/P: Assessment and plan
Plan for treatment
c with line above
With
B/O
Because of
CA
Cancer
etOH
Ethyl alcohol
H/O or h/o
History of
hs
Bedtime, at bedtime (hour of sleep)
I and O
Intake and output
LMP
Last menstrual period
N/A
Not available or applicable
NKDA
No known drug allergies
N and V
Nausea and vomiting
OB
Obstetrics
p with line above
Post or after
P
Pulse
p.c.
After meals (post cebum)
pt
Patient
PTA
Prior to admission or arrival at site
Post-op
Post-operative
PP
Postpartum or post-prandial (after eating)
PRN (prn)
As necessary (pro re nata)
P/Y or PY
Pack year (packs per day x years smoking)
q
every
qd
Every day
qh
Every hour
q2h
Every two hours
qod
Every other day
R/O
Rule out
s with line above
Without
S/P or s/p
Status post
Si/Sx
Signs and symptoms
tid
three times per day
V/D
Vomiting and diarrhea
SOMR
Source-Oriented Medical Record
POMR
Problem-Oriented Medical Record. Most Common
SOAP or SOAPER
S - Subjective information O - Objective information A - Assessment and/or diagnosis P - Plan for treatment E - Educating the patient R - Response of the patient to the education and care provided
CHEDDAR
C - Chief Complaint
H - History of all relevant information
E - Examination of relevant systems
D - Details of complaint and observed problems
D - Drugs, with dosages, currently being taken
A - Assessment based on diagnostics
R - Returning visit for follow up
A typical asthma medication would be:
Bronchodilator
A patient is being tested for color vision deficiency. Which of the following tests should the CCMA perform? Snellen, Jaeger, Ishihara, or Pelli-Robson?
Ishihara
Generally, upon conclusion of a patient’s history, you should:
Take and record vital signs
