Charting Flashcards
1
Q
FHx
A
Family history
Lists diseases + conditions in family that the patient may be at risk of having
2
Q
HIPAA
A
Health Insurance Portability and Accountability Act
Federal law; standards for protecting pt information
3
Q
HPI
A
History of present illness
Describes development of the illness
4
Q
pt
A
patient
5
Q
r/o
A
rule out (e.g. X-ray of the wrists r/o fracture)
6
Q
ROS
A
Review of systems
Checklist for pt Sx; grouped by body system
7
Q
s/p
A
Status post (after)
ex. Headache s/p fall
8
Q
SHx
A
Social history
Addresses substance use, occupation, diet exercise, living situation, marital status, etc.
whatever they do in life that affects their Sx
9
Q
Sx
A
symptoms
10
Q
Tx
A
treatment
11
Q
UTD
A
Up to date (ex. vaccination utd)
12
Q
WNL
A
Within normal limits (normal, not of concern)
13
Q
A
