Charting Flashcards
Sx
Symptoms
FHx
A part of the medical chart that lists diseases and health conditions in your family
Why is the FHx obtained?
It is a part of the medical chat listing diseases and health conditions in your family which may increase the patient’s health risks.
HIPAA
Health Insurance Portability and Accountability Act
Which federal law provides national standards to protect sensitive patient health information?
HIPAA
What does HPI mean?
History of Present Illness
Define HPI.
A part of medical chart describing the development of the illness.
Pt
Patient
r/o
Rule Out
Review of System (ROS)
Its a part of the Sx Checklist of the medical chart. The symptoms are grouped by body system (cardiovascular, skin, etc.)
What is the abbreviation for Status Post?
s/p
What is the definition of Status Post?
After (Hint: s/p)
Example “headache s/p fall”
What does the abbreviation SHx stand for?
Social History
What part of the chart addresses substance abuse, occupation,diet exercise, living situation, marital status, etc.?
Social History (SHx)
Abbreviation for Treatment?
Tx
What is the abbreviation for Within Normal Limits?
WNL definition Normal or not of concern.
Define Palpation
Medical definition of “touch”
Where does the subjective information come from?
The person giving the patient history, typically the patient, caregiver or loved one
Define Chief Complaint
Main reason for the visit
History of Present Illness definition
HPI is the story of the chief complaint.
Review of Systems abbreviation is…?
ROS is inventory of body systems obtained through a series of questions to identify patient sx.
What are the HPI elements?
Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx, and/or Context.
Medical term for Nose Bleed
Epistaxis
Erythema
Medical term for redness
