standard headings in health care documents Flashcards

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1
Q

CC

A

Chief Complaint

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2
Q

HPI

A

History of Present Illness

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3
Q

PMH

A

Past Medical (and surgical) History

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4
Q

FH

A

Family History

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5
Q

SH

A

Social History

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6
Q

ROS

A

Review of System

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7
Q

PE

A

Physical Examination

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8
Q

Dx

A

Diagnosis

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9
Q

EPRs

A

electronic patient records

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10
Q

CC

A

chief complaint

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11
Q

D/C

A

discharge; dicontinue

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12
Q

DS

A

discharge summary

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13
Q

DX, Dx

A

diagnosis

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14
Q

EHR

A

electronic health record

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15
Q

EMR

A

electronic medical record

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16
Q

EPR

A

electronic patient record

17
Q

FH

A

family history

18
Q

H&P

A

history and physical (examination)

19
Q

HIPAA

A

Health Insurance Portability and Accountability Act

20
Q

HPI

A

history of present illness

21
Q

ISMP

A

Institute of Safe Medication Practices

22
Q

PE

A

physical examination

23
Q

PMH

A

Past medical ( and surgical) history

24
Q

ROS

A

review of systems

25
Q

SH

A

social history