standard headings in health care documents Flashcards
1
Q
CC
A
Chief Complaint
2
Q
HPI
A
History of Present Illness
3
Q
PMH
A
Past Medical (and surgical) History
4
Q
FH
A
Family History
5
Q
SH
A
Social History
6
Q
ROS
A
Review of System
7
Q
PE
A
Physical Examination
8
Q
Dx
A
Diagnosis
9
Q
EPRs
A
electronic patient records
10
Q
CC
A
chief complaint
11
Q
D/C
A
discharge; dicontinue
12
Q
DS
A
discharge summary
13
Q
DX, Dx
A
diagnosis
14
Q
EHR
A
electronic health record
15
Q
EMR
A
electronic medical record
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
SH
social history
