Charting Flashcards
Family History (FHx)
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
Health Insurance Portability and Accountability Act (HIPAA)
Federal law that provides national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge
History of present illness (HPI)
A part of the medical chart describing the development of the illness
pt
Patient
r/o
Rule Out
Review of systems (ROS)
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
s/p
Status Post (after)
Social History (SHx)
A part of the chart addresses substance use, occupation, diet, exercise, living situation, marital status, etc.
Sx
Symptoms
Tx
Treatment
UTD
Up to Date
WNL
Within Normal Limits (normal, not of concern)