Charting Flashcards

1
Q

Family History (FHx)

A

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

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2
Q

Health Insurance Portability and Accountability Act (HIPAA)

A

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

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3
Q

History of present illness (HPI)

A

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

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4
Q

pt

A

Patient

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5
Q

r/o

A

Rule Out

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6
Q

Review of systems (ROS)

A

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

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7
Q

s/p

A

Status Post (after)

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8
Q

Social History (SHx)

A

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

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9
Q

Sx

A

Symptoms

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10
Q

Tx

A

Treatment

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11
Q

UTD

A

Up to Date

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12
Q

WNL

A

Within Normal Limits (normal, not of concern)

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