Medical Records and Abbreviations Flashcards
EHR
electronic health record: the patient’s chart from a single clinic or practice visit
EMR
electronic medical record: more global and holistic with information from multiple doctors over multiple visits
Chief complaint
the main reason for the patient’s visit. It might include things like sore throat, pain in a joint, or a rash
History of present illness
It is the story of the patient’s problem. It usually includes things like when the symptoms began and if there was a particular event that caused the symptoms like slamming your fingers in a car door
PMH
past medical history: tells the health care provider if you’ve had any other significant past illnesses like high blood pressure, asthma, or diabetes. The patient’s family and social history are also common elements in medical records. As with past medical and surgical histories, family and social histories also have two commonly used abbreviations. History can be abbreviated as H or Hx
S.O.A.P
The S in SOAP Note stands for subjective. In medical records, this section includes what the patient says. If something is subjective, that means it is influenced by a person’s opinions, feelings, or preferences. This section should record exactly what the patient says, even if it doesn’t match what the clinician thinks.
O in SOAP Note stands for objective. In medical records, this section includes what the tests reveal. If something is objective, that means it is not influenced by personal feelings or opinions, but rather represents fact.
A in SOAP Note stands for assessment. This section contains the practitioner’s assessment of what is causing the subjective complaints and objective test results. We call this the diagnosis, abbreviated Dx. Sometimes a patient might not have a clear diagnosis. In this case, the practitioner may include a differential diagnosis, abbreviated DDx, which is a list of possible conditions that might be causing the problem
The P in SOAP Note stands for plan. This section obviously tells you what the practitioner plans to do about their findings.
