Charting

Question 1

FHx

Answer 1

Family history; lists the diseases and health conditions of your family that may have contributed to the patient’s being at risk of the disease/condition

Question 2

HIPAA

Answer 2

Health Insurance Portability and Accountability Act; it is a federal law and a national standard to protect patient’s health information (PHI) from being dislosed without the pt’s consent or knowledge

Question 3

HPI

Answer 3

History of present illness; this is where the patient describes the development of the illness!

Question 4

Pt

Answer 4

Abbreviation for Patient

Question 5

r/o

Answer 5

Rule Out (example: an x-ray was analyzed, and the doctor says we do not have to consider a fracture after seeing the xray on the wrist of the pt. Hence, “x-ray of wrist to r/o fracture”)

Question 6

ROS

Answer 6

Review of SYSTEMS (not symptoms); this is the checklist of the symptoms the pt has or does not have. The symptoms are GROUPED by body system!

Question 7

s/p

Answer 7

Status post, which means “after”. Example: headache s/p fall; concussion s/p fall; fracture s/p fall; infection s/p laceration & superficial skin abrasion.

Question 8

SHx

Answer 8

Social history; this is where we record the substance abuse, alcohol, drugs, occupation, diet exercise, living situation, marital status, etc (Dying wife, wife died of something).

Question 9

Sx

Answer 9

Symptoms

Question 10

Tx

Answer 10

Treatment

Question 11

UTD

Answer 11

Up to date (example: vaccination utd)

Question 12

WNL

Answer 12

within normal limits (normal, not concerning); usually added or used for lab results!