Charting

Question 1

Sx

Answer 1

Symptoms

Question 2

FHx

Answer 2

A part of the medical chart that lists diseases and health conditions in your family

Question 3

Why is the FHx obtained?

Answer 3

It is a part of the medical chat listing diseases and health conditions in your family which may increase the patient’s health risks.

Question 4

HIPAA

Answer 4

Health Insurance Portability and Accountability Act

Question 5

Which federal law provides national standards to protect sensitive patient health information?

Answer 5

HIPAA

Question 6

What does HPI mean?

Answer 6

History of Present Illness

Question 7

Define HPI.

Answer 7

A part of medical chart describing the development of the illness.

Question 8

Pt

Answer 8

Patient

Question 9

r/o

Answer 9

Rule Out

Question 10

Review of System (ROS)

Answer 10

Its a part of the Sx Checklist of the medical chart. The symptoms are grouped by body system (cardiovascular, skin, etc.)

Question 11

What is the abbreviation for Status Post?

Answer 11

s/p

Question 12

What is the definition of Status Post?

Answer 12

After (Hint: s/p)

Example “headache s/p fall”

Question 13

What does the abbreviation SHx stand for?

Answer 13

Social History

Question 14

What part of the chart addresses substance abuse, occupation,diet exercise, living situation, marital status, etc.?

Answer 14

Social History (SHx)

Question 15

Abbreviation for Treatment?

Answer 15

Tx

Question 16

What is the abbreviation for Within Normal Limits?

Answer 16

WNL definition Normal or not of concern.

Question 17

Define Palpation

Answer 17

Medical definition of “touch”

Question 18

Where does the subjective information come from?

Answer 18

The person giving the patient history, typically the patient, caregiver or loved one

Question 19

Define Chief Complaint

Answer 19

Main reason for the visit

Question 20

History of Present Illness definition

Answer 20

HPI is the story of the chief complaint.

Question 21

Review of Systems abbreviation is…?

Answer 21

ROS is inventory of body systems obtained through a series of questions to identify patient sx.

Question 22

What are the HPI elements?

Answer 22

Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx, and/or Context.

Question 23

Medical term for Nose Bleed

Answer 23

Epistaxis

Question 24

Erythema

Answer 24

Medical term for redness