Medical Medical TerminologyTerminology

A Programmed Learning Approach to A Programmed Learning Approach to the Language of Health Care, 2the Language of Health Care, 2ndnd EditionEdition

Chapter 2:Chapter 2:

Health Care Health Care RecordsRecords

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History and Physical History and Physical (H&P)(H&P)

Document of medical history and Document of medical history and findings from physical examinationfindings from physical examination

Includes:Includes: Subjective information – historySubjective information – history

obtained from patient including obtained from patient including his/her personal perceptionshis/her personal perceptions

Objective information – physicalObjective information – physicalfacts and observations made by an facts and observations made by an examinerexaminer

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History (Hx)History (Hx)

Record of the patient’s personal Record of the patient’s personal medical history including past medical history including past injuries, illnesses, operations, injuries, illnesses, operations, defects, and habitsdefects, and habits

Includes: chief complaint, history Includes: chief complaint, history of present illness, past history, of present illness, past history, family history, occupational family history, occupational history and review of systemshistory and review of systems

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History (Hx) History (Hx) AbbreviationsAbbreviations

CCCC Chief ComplaintChief Complaint Brief description of why patient is seeking Brief description of why patient is seeking

care care

c/oc/o complains ofcomplains of Used in describing complaintUsed in describing complaint

PIPI oror HPIHPI Present Illness Present Illness or or History of Present IllnessHistory of Present Illness

Notation of duration and severity of complaintNotation of duration and severity of complaint How bad is it? How long have they had it?How bad is it? How long have they had it?

SxSx symptom symptom Evidence of illness that the patient reportsEvidence of illness that the patient reports

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History (Hx) History (Hx) AbbreviationsAbbreviations

PH PH or or PMHPMH Past History Past History oror Past Medical HistoryPast Medical History

Notation of surgeries, injuries, Notation of surgeries, injuries, physical defects, medications, physical defects, medications, allergiesallergies

UCHDUCHD usual childhood diseasesusual childhood diseases

NKANKA no known allergiesno known allergies

NKDANKDA no known drug allergiesno known drug allergies

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History (Hx) History (Hx) AbbreviationsAbbreviations

FHFH Family HistoryFamily History Notes about the state of health of Notes about the state of health of

immediate family membersimmediate family members Example: FH: father, age 58, mother, Example: FH: father, age 58, mother,

age 54, brother, age 32, all L&Wage 54, brother, age 32, all L&W

A&WA&W alive and wellalive and well

L&WL&W living and wellliving and well

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History (Hx) History (Hx) AbbreviationsAbbreviations

SHSH Social HistorySocial History Recreational interests, hobbies, use Recreational interests, hobbies, use

of tobacco/drugsof tobacco/drugs

OHOH Occupational HistoryOccupational History Work habits that may involve work Work habits that may involve work

related risksrelated risks

ROSROS oror SRSR Review of Systems Review of Systems oror Systems ReviewSystems Review

Questions related to function of the Questions related to function of the body systemsbody systems

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Physical Exam (Px or Physical Exam (Px or PE)PE)

Document of physical Document of physical examination of a patient including examination of a patient including notations of positive and negative notations of positive and negative findingsfindings Includes: results of diagnostic testingIncludes: results of diagnostic testing Sign – objective evidence of diseaseSign – objective evidence of disease

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Physical Exam Physical Exam AbbreviationsAbbreviations

HEENTHEENT head, eyes, ears, nose, head, eyes, ears, nose, and throatand throat

PERRLAPERRLA pupils equal, round, and pupils equal, round, and reactive to light and reactive to light and accommodationaccommodation

NADNAD no acute distressno acute distress

WNLWNL within normal limitswithin normal limits

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History and PhysicalHistory and Physical

Impression (IMP)Impression (IMP)

Diagnosis (Dx)Diagnosis (Dx)

Assessment (A)Assessment (A) identification of a disease or condition identification of a disease or condition

after evaluation of all subjective and after evaluation of all subjective and objective informationobjective information

Rule out (R/O)Rule out (R/O) a a differential diagnosisdifferential diagnosis noted when one or noted when one or

more diagnoses are suspect; requires more diagnoses are suspect; requires further testing to verify or eliminate each further testing to verify or eliminate each possibilitypossibility

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History and PhysicalHistory and Physical

PLAN,PLAN,RECOMMENDATION,RECOMMENDATION,

ororDISPOSITIONDISPOSITION

outline of the treatment plan designed outline of the treatment plan designed to remedy the patient’s condition, to remedy the patient’s condition, which includes instructions to the which includes instructions to the patient and orders for medications, patient and orders for medications, diagnostic tests, or therapiesdiagnostic tests, or therapies

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SOAP Progress NotesSOAP Progress Notes

Progress notes made after the initial Progress notes made after the initial history and physical is recorded. The history and physical is recorded. The letters represent the order in which letters represent the order in which progress is noted:progress is noted:SS subjectivesubjective – – that which the patient that which the patient describesdescribes

OO objectiveobjective – – observable information, such as observable information, such as test results, blood pressure readings, etc.test results, blood pressure readings, etc.

A A assessmentassessment – – progress and evaluation of progress and evaluation of the the effectiveness of the planeffectiveness of the plan

P P planplan – – decision to proceed or alter strategydecision to proceed or alter strategy

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Common Hospital Common Hospital RecordsRecords

History and PhysicalHistory and Physical Physician’s ordersPhysician’s orders Diagnostic tests/laboratory Diagnostic tests/laboratory

reportsreports Nurse’s notesNurse’s notes Physician’s progress notesPhysician’s progress notes Consultation reportConsultation report Operative reportOperative report Pathology reportPathology report Anesthesiologist’s reportAnesthesiologist’s report

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Diagnostic Imaging Diagnostic Imaging ModalitiesModalities

IONIZING IMAGINGIONIZING IMAGING A process that changes the electrical A process that changes the electrical charge of atoms with a possible effect on charge of atoms with a possible effect on body cells; overexposure can have body cells; overexposure can have harmful side effects, e.g., cancerharmful side effects, e.g., cancer

RADIOGRAPHY (X-RAY)RADIOGRAPHY (X-RAY) COMPUTED TOMOGRAPHY COMPUTED TOMOGRAPHY oror

COMPUTED AXIAL TOMOGRAPHYCOMPUTED AXIAL TOMOGRAPHY NUCLEAR MEDICINE IMAGING NUCLEAR MEDICINE IMAGING oror

RADIONUCLIDE ORGAN IMAGINGRADIONUCLIDE ORGAN IMAGING

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Diagnostic Imaging Diagnostic Imaging ModalitiesModalities

NONIONIZING IMAGINGNONIONIZING IMAGING an imaging process that an imaging process that presents no apparent risk presents no apparent risk

MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING SONOGRAPHYSONOGRAPHY

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Common Terms Common Terms Related to DiseaseRelated to Disease

acute vs. chronicacute vs. chronic

benign vs. malignantbenign vs. malignant

localized vs. systemiclocalized vs. systemic

exacerbation vs. remissionexacerbation vs. remission

progressiveprogressive

recurrentrecurrent

degenerativedegenerative

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Common Terms Common Terms Related to DiseaseRelated to Disease

symptom (subjective)symptom (subjective)

sign (objective)sign (objective)

diagnosis (through knowing)diagnosis (through knowing)

syndrome (running together)syndrome (running together)

prognosis (before knowing)prognosis (before knowing)

etiology (study of cause)etiology (study of cause)

idiopathic (disease of individual)idiopathic (disease of individual)

sequelasequela

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Common Terms Common Terms Related to DiseaseRelated to Disease

good vs. malaisegood vs. malaise

febrile vs. afebrilefebrile vs. afebrile

markedmarked

equivocalequivocal

noncontributorynoncontributory

unremarkableunremarkable

morbiditymorbidity

mortalitymortality

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Common Patient Care Common Patient Care AbbreviationsAbbreviations

Use only those acceptable to Use only those acceptable to workplaceworkplace

emergency facilityemergency facility ER, ECUER, ECUplace to recover after surgeryplace to recover after surgery PAR, PACUPAR, PACUregistered bed patientregistered bed patient IPIPcare before surgerycare before surgery preop, pre-oppreop, pre-oppatientpatient ptptwell-developed, well-nourishedwell-developed, well-nourishedWDWNWDWNbathroom privilegesbathroom privileges BRPBRP

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Common Patient Care Common Patient Care AbbreviationsAbbreviations

shortness of breathshortness of breath SOBSOBtreatmenttreatment Tx, TrTx, Trtemperature, pulse, temperature, pulse, T, P, T, P, respiration, blood pressure respiration, blood pressure R, R, BP =BP = (vital signs)(vital signs) VSVS increase increase decreasedecrease degree or hourdegree or hour °°pound or number signpound or number sign ##

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Error Prone Error Prone Abbreviations and Abbreviations and SymbolsSymbols

Medical errors caused by illegible writing Medical errors caused by illegible writing and misinterpretations of abbreviations and misinterpretations of abbreviations and symbols have led health care and symbols have led health care agencies, such as the Joint Commission agencies, such as the Joint Commission on Accreditation of Healthcare on Accreditation of Healthcare Organizations (JCAHO), to require that Organizations (JCAHO), to require that medical facilities publish lists of medical facilities publish lists of authorized abbreviations for use by all authorized abbreviations for use by all personnel, including a list of personnel, including a list of abbreviations and symbols that are abbreviations and symbols that are unacceptable.unacceptable.

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Error Prone Error Prone Abbreviations and Abbreviations and SymbolsSymbols

q. d q. d every dayevery day mistaken for q.i.d when the period mistaken for q.i.d when the period

after the “q” is sloppily written to after the “q” is sloppily written to look like an “i”look like an “i”

spell out “daily”spell out “daily”

q.o.d. q.o.d. every other dayevery other day mistaken for q.d when the “o” is mistaken for q.d when the “o” is

mistaken for a periodmistaken for a period spell out “every other day”spell out “every other day”

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Error Prone Error Prone Abbreviations and Abbreviations and SymbolsSymbols

DC, D/C DC, D/C discharge, discontinuedischarge, discontinue mistaken for “discontinue” when followed by mistaken for “discontinue” when followed by

medications prescribed at the time of medications prescribed at the time of dischargedischarge

spell out “discontinue” or “discharge”spell out “discontinue” or “discharge”

>, < >, < greater than, less thangreater than, less than mistaken for each othermistaken for each other spell out “greater than” or “less than”spell out “greater than” or “less than”

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Error Prone Error Prone Abbreviations and Abbreviations and SymbolsSymbols

AS, AD, AU left ear, right ear, both AS, AD, AU left ear, right ear, both earsearsOS, OD, OU left eye, right eye, both OS, OD, OU left eye, right eye, both eyeseyes

mistaken for each othermistaken for each other spell out “left ear,” “right eye,” etc.spell out “left ear,” “right eye,” etc.

SC SC or or SQ SQ subcutaneoussubcutaneous mistaken for SL (sublingual) or “5 every”mistaken for SL (sublingual) or “5 every” spell out "subcutaneously“ or use sub-Qspell out "subcutaneously“ or use sub-Q

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Pharmaceutical Pharmaceutical Abbreviations and Abbreviations and SymbolsSymbols

MetricMetric cc (cubic centimeter)cc (cubic centimeter) cm (centimeter)cm (centimeter) g g oror gm (gram) gm (gram) kg (kilogram)kg (kilogram) L (liter)L (liter) mg (milligram)mg (milligram) ml ml oror mL (milliliter) mL (milliliter) Note: Note: 1 cc = 1 1 cc = 1

mLmL mm (millimeter)mm (millimeter) cu mm cu mm or or mmmm3 3 (cubic millimeter)(cubic millimeter)

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Pharmaceutical Pharmaceutical Abbreviations and Abbreviations and SymbolsSymbols

ApothecaryApothecary fl oz (fluid ounce)fl oz (fluid ounce) gr (grain)gr (grain) gt (drop)gt (drop) gtt (drops)gtt (drops) dr (dram)dr (dram) oz (ounce)oz (ounce) lb or # (pound)lb or # (pound) qt (quart)qt (quart)

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Medication Medication Administration - Drug Administration - Drug FormsForms

Solid and Semisolid FormsSolid and Semisolid Forms Tablet (tab)Tablet (tab) Capsule (cap)Capsule (cap) Suppository (suppos)Suppository (suppos)

Liquid FormsLiquid Forms FluidFluid Parenteral (ID, sub-Q, IM, IV)Parenteral (ID, sub-Q, IM, IV) Cream, lotion, ointmentCream, lotion, ointment Other delivery systemsOther delivery systems

TransdermalTransdermal ImplantImplant

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Parenteral Drug Parenteral Drug AdministrationAdministration

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The PrescriptionThe Prescription

Physician’s written direction for Physician’s written direction for dispensing or administering a dispensing or administering a medication for a patientmedication for a patient

Must be written in a specific Must be written in a specific formatformat

RxRx Symbol at beginning of prescriptionSymbol at beginning of prescription Stands for recipeStands for recipe

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Drug NamesDrug Names

Chemical nameChemical name – assigned to – assigned to drug at the time it is formulateddrug at the time it is formulated

Generic nameGeneric name – the official, – the official, nonproprietary name given a nonproprietary name given a drugdrug

TradeTrade or or brandbrand – the – the manufacturer's name for a drugmanufacturer's name for a drug

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Drug NamesDrug Names

For example:For example:

Chemical name:Chemical name: 1-[3-(6,7-dihydro-1- 1-[3-(6,7-dihydro-1-ethyl-7-oxo-3-propyl-1H-pyrazolo[4,3-ethyl-7-oxo-3-propyl-1H-pyrazolo[4,3-

pyrimidin-5-yl)-4-pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4-ethoxyphenyl]sulfonyl]-4-methylpiperazine citratemethylpiperazine citrate

Generic name:Generic name: sildenafil sildenafil

TradeTrade or or Brand name:Brand name: Viagra Viagra

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Sample PrescriptionSample Prescription

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Military TimeMilitary Time

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CorrectionsCorrections

Careful clarification of an error Careful clarification of an error when making an entry in a when making an entry in a medical record is essentialmedical record is essential

Include:Include: DateDate The abbreviation “corr”The abbreviation “corr” Initials of person making correctionsInitials of person making corrections

Do not use correction fluid!Do not use correction fluid!

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Proper Correction of a Proper Correction of a Medical RecordMedical Record