From Chapter 1

Question 0

Condition

Answer 0

An update about the status of the patients symptoms upon reevaluation or discharge

Question 1

Caveat

Answer 1

An acceptable reason as to why the physician is unable to obtain a patients complete history

Question 2

Diagnosis

Answer 2

What the doctor has determined to be the cause of the patients symptoms

Question 3

Disposition

Answer 3

Where the patient will be going after leaving the medical facility

Question 4

Course notes

Answer 4

A chronological timeline of what occurred during a patients stay in the medical facility

Question 5

Chief complaint

Answer 5

The primary reason the patient came to see the physician

Question 6

Location

Answer 6

The physical location of the pain

Question 7

Duration

Answer 7

The amount of time that has passed since the pain or symptom began

Question 8

Timing

Answer 8

The frequency of the pain or symptoms

Question 9

Quality

Answer 9

The type of pain

Question 10

Severity

Answer 10

The intensity of the pain

Question 11

Modifying factors

Answer 11

What makes the pain better or worse

Question 12

Associated symptoms

Answer 12

Symptoms related to the chief complaint

Question 13

EKG

Answer 13

A test that checks for problems with the electrical activity of the heart

Question 14

Family history

Answer 14

Contains the hereditary conditions of the patients family members

Question 15

History of present Illness (hpi)

Answer 15

A logical story of what lead the patient to come to the medical facility

Question 16

Labs

Answer 16

Tests performed on body fluids and excretions in order to get information about the health of a patient

Question 17

Medical history

Answer 17

Includes anything pertaining to the patients personal medical history (including preexisting conditions or surgeries)

Question 18

Orders

Answer 18

Directions given by the doctor to perform tests or administer treatment or medication

Question 19

Past medical, family, social history (pfsh)

Answer 19

Where you would document the patients personal medical, surgical, family and social history

Question 20

Physical examination (pe)

Answer 20

The objective process by which a doctor investigates a patients body for signs of disease

Question 21

Prescription

Answer 21

A written document given to a patient authorizing a medicine or treatment

Question 22

Procedures

Answer 22

Actions performed by the physician during a patients stay in the medical facility, usually as part of treatment for the patients presenting problem (chief complaint)

Question 23

Radiology

Answer 23

The use of imaging to both diagnose and treat disease within human body

Question 24

Review of systems (ros)

Answer 24

Where you would document all of the patients other symptoms (positive and negative) that are not related to the chief complaint

Question 25

Social history

Answer 25

An age appropriate review of the patients past and current activities

Question 26

Vital signs

Answer 26

Indicators that may be watched measures and monitored to check an individual’s level of physical functioning