Charting

Question 1

Family History (FHx)

Answer 1

A part of the medical chart that lists diseases and health conditions in your family that may put the patient at an increased risk of also having

Question 2

Health Insurance Portability and Accountability Act (HIPAA)

Answer 2

Federal law that provides national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge

Question 3

History of Present Illness (HPI)

Answer 3

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

Question 4

pt

Answer 4

Patient

Question 5

r/o

Answer 5

Rule Out (e.g. X-Ray of the wrist r/o fracture)

Question 6

Review of System (ROS)

Answer 6

A part of the medical chart that is a checklist of the symptoms the patient has or does not have. The symptoms are grouped by body system (cardiovascular, skin, etc.)

Question 7

s/p

Answer 7

Status Post (after) example: Headache s/p fall

Question 8

Social History (SHx)

Answer 8

A part of the chart addresses substance use, occupation, diet, exercise, living situation, marital status, etc.

Question 9

Sx

Answer 9

Symptoms

Question 10

Tx

Answer 10

Treatment

Question 11

UTD

Answer 11

Up to Date (Example: vaccination utd)