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Medical Terminology
Health Care Records
173
Medical
Professional
09/02/2009
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Term
history and physical (H&P)
 Definition
documents the patient's medical history and findings from the physical examination.
Term
documents subjective information from the patient's personal statement about his or her medical history and includes information regarding past injuries, illnesses, operations, defects, and habits
 Definition
history (Hx)
Term
patient's reason for seeking medical care
 Definition
chief complaint (CC)
Term
the abbreviation c/o
 Definition
complains of
Term
present illness (PI), or history of present illness (HPI)
 Definition
Details of the complaint
Term
symptoms (Sx),
 Definition
subjective evidence of illness, indicate what the patient is experiencing.
Term
past history (PH), or past medical history (PMH)
 Definition
record of information about the patient's past illnesses, starting with childhood, and it includes surgical operations, injuries, physical defects, medications, and allergies
Term
UCHD (usual childhood diseases)
 Definition
“usual” or commonly contracted illnesses during childhood.
Term
NKA
 Definition
no known allergies),
Term
NKDA
 Definition
(no known drug allergies)
Term
family history (FH)
 Definition
he state of health of the immediate family members (mother, father, and siblings)
Term
social history (SH)
 Definition
patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol.
Term
occupational history (OH)
 Definition
record of work habits that may involve health risks
Term
eview of systems (ROS), or a systems review (SR)
 Definition
a head-to-toe review of the functions of all body systems.
Term
physical examination (PE), or a physical (Px)
 Definition
to obtain objective information, facts that can be seen or detected by testing.
Term
Signs
 Definition
objective evidence of disease
Term
HEENT
Definition
(head, eyes, ears, nose, and throat)
Term
PERRLA
Definition
(pupils equal, round, and reactive to light and accommodation)
Term
NAD
Definition
no acute distress
Term
WNL
Definition
within normal limits).
Term
impression (IMP), diagnosis (Dx), or assessment (A)
 Definition
identification of a disease or condition is recorded
Term
R/O (rule out)
 Definition
differential diagnosis
Term
plan (P)
 Definition
recommendation or disposition
Term
plan (P),
 Definition
strategies designed to remedy the patient's condition, including instructions to the patient and orders for medications, diagnostic tests, or therapies.
Term
progress notes
 Definition
document the patient's continued care
Term
SOAP
 Definition
S: Subjective that which the patient describes
O: Objective observable information (e.g., test results and blood pressure readings)
A: Assessment patient's progress and evaluation of the plan's effectiveness; any newfound problem or diagnosis is also noted here
P: Plan decision to proceed or to alter the plan strategy
Term
difficult case, a specialist may be called in by the attending physician,
 Definition
consultation report
Term
operative report
 Definition
surgical remedy
Term
anesthesiologist's report
 Definition
nesthesia details, including the drugs used, the dose and time given, and the patient's vital status throughout the procedure.
Term
informed consent
 Definition
form must be signed by the patient to show that he or she has been advised of the risks and benefits of the proposed treatment as well as any alternatives.
Term
Ancillary reports
 Definition
dditional procedures and therapies, including diagnostic tests and pathology reports
Term
discharge summary
 Definition
The final hospital document, which is recorded at the time of discharge
Term
discharge summar
 Definition
(also termed the clinical resume, clinical summary, or discharge abstract)
Term
ionizing
 Definition
process that changes the electrical charge of atoms and has a possible effect on body cells
Term
x-ray
 Definition
radiography
Term
CT
 Definition
computed tomography
Term
MRI
 Definition
magnetic resonance imaging
Term
US
 Definition
sonography
Term
radiologic technologist, also known as radiographer
 Definition
person who takes the x-ray
Term
radiologist
 Definition
hysician specializing in the study of radiology
Term
Computed tomography
 Definition
CT
Term
CAT
 Definition
computed axial tomography
Term
Nuclear Medicine Imaging or Radionuclide Organ Imaging
 Definition
uses an injected or ingested radioactive isotope (also called a radionuclide), or a chemical that has been tagged with radioactive compounds that emit gamma rays
Term
Magnetic resonance imaging (MRI)
 Definition
nonionizing imaging technique using magnetic fields and radiofrequency waves to visualize anatomic structures within the body
Term
Sonography
 Definition
diagnostic ultrasound (U/S or US)
Term
acute
 Definition
sharp; having intense, often severe symptoms and a short course
Term
chronic
 Definition
a condition that develops slowly and persists over a period of time
Term
chronic
 Definition
a condition that develops slowly and persists over a period of time
Term
benign
 Definition

bē-n[image]n′ mild or noncancerous
Term
malignant
 Definition
harmful or cancerous
Term
degeneration
 Definition
gradual deterioration of normal cells and body functions
Term
degenerative disease
 Definition
any disease in which deterioration of the structure or function of tissue occurs
Term
diagnosis
 Definition
determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings (results) (dia = through; gnosis = knowing)
Term
etiology
 Definition
study of the cause of a disease
Term
exacerbation
 Definition
increase in the severity of a disease, with aggravation of symptoms
Term
remission
 Definition
a period in which symptoms and signs stop or abate
Term
febrile
 Definition
relating to a fever (elevated temperature)
Term
idiopathic
 Definition
a condition occurring without a clearly identified cause
Term
localized
 Definition
limited to a definite area or part
Term
systemic
 Definition
relating to the whole body rather than to only a part
Term
malaise
 Definition
a feeling of uneasiness or discomfort; often the first indication of illness
Term
marked
 Definition
significant
Term
morbidity
 Definition
sick; a diseased state
Term
mortality
 Definition
the state of being subject to death
Term
prognosis
 Definition
foreknowledge; prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease; often noted in one word
Term
progressive
 Definition
pertaining to the advance of a condition as the signs and symptoms increase in severity
Term
prophylaxis
 Definition
a process or measure that prevents disease
Term
recurrent
 Definition
to occur again; describes a return of symptoms and signs after a period of quiescence
Term
sequela
 Definition
a disorder or condition usually resulting from a previous disease or injury
Term
sign
 Definition
a mark; objective evidence of disease that can be seen or verified by an examiner
Term
symptom
 Definition
subjective evidence of disease that is perceived by the patient and often noted in his or her own words
Term
syndrome
 Definition
a running together; combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease
Term
noncontributory
 Definition
not involved in bringing on the condition or result
Term
unremarkable
 Definition
common; not out of the ordinary or significant
Term
(JCAHO)
 Definition
Joint Commission on Accreditation of Healthcare Organizations
Term
CCU
 Definition
coronary (cardiac) care unit
Term
ECU
 Definition
emergency care unit
Term
ER
 Definition
emergency room
Term
ICU
 Definition
intensive care unit
Term
IP
 Definition
inpatient
Term
OP
 Definition
outpatient
Term
OR
 Definition
operating room
Term
PACU
 Definition
postanesthetic care unit
Term
PAR
 Definition
postanesthetic recovery
Term

 

post-op or postop

 Definition
postoperative (after surgery)
Term
pre-op or preop
 Definition
preoperative (before surgery)
Term
RTC
 Definition
return to clinic
Term
RTO
 Definition
return to office
Term
[image]
 Definition
bilateral
Term
BRP
 Definition
bathroom privileges
Term
CP
 Definition
chest pain
Term
DC or D/C
 Definition
discharge, discontinue
Term
ETOH
 Definition
ethyl alcohol
Term
[image]
 Definition
 left
Term
[image]
 Definition

 right

 
Term
[image]
 Definition
 murmur
Term
pt
 Definition
patient
Term
RRR
 Definition
 regular rate and rhythm
Term
SOB
 Definition
 shortness of breath
Term
Tr
 Definition
 treatment
Term
Tx
 Definition
treatment or traction
Term
VS
 Definition
vital signs
Term
T
 Definition
 temperature
Term
P
 Definition
pulse
Term
R
 Definition
respiration
Term
BP
 Definition
 blood pressure
Term
Ht
 Definition
 height
Term
Wt
 Definition
 weight
Term
WDWN
 Definition
well-developed and well-nourished
Term
y/o or y.o
 Definition
. year old
Term
#
 Definition
number or pound; if used before a numeral, it means number (e.g., #2 = number 2); if used after a numeral, it means pound (e.g., 150# = 150 pounds)
Term
C
 Definition
Celsius, centigrade
Term
F
 Definition
 Fahrenheit
Term
♀
 Definition
 female
Term
♂
 Definition
male
Term
°
 Definition
 degree, or hour
Term
↑
 Definition
 increased
Term
↓
 Definition
 decreased
Term
θ
 Definition
none or negative
Term
[image]
 Definition
standing
Term
[image]
 Definition
 sitting
Term
[image]
 Definition
 lying
Term
meter (m)
 Definition
length (39.37 inches)
Term
liter (L)
 Definition
volume (1.0567 U.S. quarts)
Term
gram (g or gm)
 Definition
weight (15.432 grains)
Term
cc
 Definition
cubic centimeter; 1 cc = 1 mL
Term
cm
 Definition
centimeter; 2.5 cm = 1 inch
Term
g or gm
 Definition
gram
Term
kg 
 Definition
kilogram;
Term
L
 Definition
liter
Term
dr 
 Definition
dram; equal to 1/8 ounce
Term
lb or # 
 Definition
pound; equal to 16 ounces
Term
qt 
 Definition
quart; equal to 32 ounces
Term
sublingual (SL) 
 Definition
under the tongue
Term
buccal 
 Definition
in the cheek
Term
  aerosol 
 Definition
spray
Term
nebulizer device
 Definition
used to produce a fine spray or mist, often in a metered dose
Term
 intradermal (ID) 
 Definition
within the skin
Term
   intramuscular (IM) 
 Definition
within the muscle
Term
   intravenous (IV
 Definition
) within the vein
Term
(SC, SQ,
 Definition
subcutaneous
Term
transdermal 
 Definition
absorption of drug through unbroken skin
Term
implant 
 Definition
a drug reservoir imbedded in the body to provide continual infusion of a medication (e.g., insulin pump)
Term
ā 
 Definition
before
Term
a.c. 
 Definition
before meals
Term
a.m. 
 Definition
before noon
Term
b.i.d. 
 Definition
twice a day
Term
h.s. 
 Definition
at the hour of sleep/bedtime
Term
noc. 
 Definition
night
Term

[image]

 
 Definition
after
Term
p.c.
 Definition
after meals
Term
p.m. 
 Definition
after noon
Term
q.d. (*)
 Definition
NEVER USE: spell out every day or daily
Term
q.o.d. (*) 
 Definition
every other day [NEVER USE: spell out every other day]
Term
STAT
 Definition
immediately
Term
wk 
 Definition
week
Term
AD 
 Definition
right ear [spell out right ear]
Term
ad lib.
 Definition
as desired
Term
amt 
 Definition
amount
Term
aq 
 Definition
water
Term
AS 
 Definition
left ear [spell out left ear]
Term
AU 
 Definition
both ears [spell out both ears]
Term
[image] 
 Definition
with
Term
NPO 
 Definition
nothing by mouth
Term
OD
 Definition
right eye [spell out right eye]
Term
per
 Definition
by or through
Term
[image]
 Definition
without
Term
[image] 
 Definition
one-half [spell out one-half or use 1/2]
Term
wa 
 Definition
while awake
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