Medical Terminology

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Medical Terminology

• A Programmed Learning Approach to the Language of
  Health Care, 2nd Edition

Chapter 2Health Care Records
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History and Physical (HP)

• Document of medical history and findings from
  physical examination
• Includes
• Subjective information historyobtained from
  patient including his/her personal perceptions
• Objective information physicalfacts and
  observations made by an examiner

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History (Hx)

• Record of the patients personal medical history
  including past injuries, illnesses, operations,
  defects, and habits
• Includes chief complaint, history of present
  illness, past history, family history,
  occupational history and review of systems

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History (Hx) Abbreviations

• CC Chief Complaint
• Brief description of why patient is seeking care
• c/o complains of
• Used in describing complaint
• PI or HPI Present Illness or
• History of Present Illness
• Notation of duration and severity of complaint
• How bad is it? How long have they had it?
• Sx symptom
• Evidence of illness that the patient reports

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History (Hx) Abbreviations
(continued)

• PH or PMH Past History or
• Past Medical History
• Notation of surgeries, injuries, physical
  defects, medications, allergies
• UCHD usual childhood diseases
• NKA no known allergies
• NKDA no known drug allergies

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History (Hx) Abbreviations
(continued)

• FH Family History
• Notes about the state of health of immediate
  family members
• Example FH father, age 58, mother, age 54,
  brother, age 32, all LW
• AW alive and well
• LW living and well

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History (Hx) Abbreviations
(continued)

• SH Social History
• Recreational interests, hobbies, use of
  tobacco/drugs
• OH Occupational History
• Work habits that may involve work related risks
• ROS or SR Review of Systems or Systems
  Review
• Questions related to function of the body systems

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Physical Exam (Px or PE)

• Document of physical examination of a patient
  including notations of positive and negative
  findings
• Includes results of diagnostic testing
• Sign objective evidence of disease

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Physical Exam Abbreviations

• HEENT head, eyes, ears, nose, and throat
• PERRLA pupils equal, round, and reactive to light
  and accommodation
• NAD no acute distress
• WNL within normal limits

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History and Physical

• Impression (IMP)
• Diagnosis (Dx)
• Assessment (A)
• identification of a disease or condition after
  evaluation of all subjective and objective
  information
• Rule out (R/O)
• a differential diagnosis noted when one or more
  diagnoses are suspect requires further testing
  to verify or eliminate each possibility

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History and Physical
(continued)

• PLAN,RECOMMENDATION,
• orDISPOSITION
• outline of the treatment plan designed to remedy
  the patients condition, which includes
  instructions to the patient and orders for
  medications, diagnostic tests, or therapies

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SOAP Progress Notes

• Progress notes made after the initial history and
  physical is recorded. The letters represent the
  order in which progress is noted
• S subjective that which the patient describes
• O objective observable information, such as
  test results, blood pressure readings, etc.
• A assessment progress and evaluation of the
  effectiveness of the plan
• P plan decision to proceed or alter strategy

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Common Hospital Records

• History and Physical
• Physicians orders
• Diagnostic tests/laboratory reports
• Nurses notes
• Physicians progress notes
• Consultation report
• Operative report
• Pathology report
• Anesthesiologists report

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Diagnostic Imaging Modalities

• IONIZING IMAGING
• A process that changes the electrical charge of
  atoms with a possible effect on body cells
  overexposure can have harmful side effects, e.g.,
  cancer
• RADIOGRAPHY (X-RAY)
• COMPUTED TOMOGRAPHY or COMPUTED AXIAL
  TOMOGRAPHY
• NUCLEAR MEDICINE IMAGING or RADIONUCLIDE ORGAN
  IMAGING

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Diagnostic Imaging Modalities
(continued)

• NONIONIZING IMAGING
• an imaging process that presents no apparent
  risk
• MAGNETIC RESONANCE IMAGING
• SONOGRAPHY

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Common Terms Related to Disease

• acute vs. chronic
• benign vs. malignant
• localized vs. systemic
• exacerbation vs. remission
• progressive
• recurrent
• degenerative

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Common Terms Related to Disease
(continued)

• symptom (subjective)
• sign (objective)
• diagnosis (through knowing)
• syndrome (running together)
• prognosis (before knowing)
• etiology (study of cause)
• idiopathic (disease of individual)
• sequela

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Common Terms Related to Disease
(continued)

• good vs. malaise
• febrile vs. afebrile
• marked
• equivocal
• noncontributory
• unremarkable
• morbidity
• mortality

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Common Patient Care Abbreviations

• Use only those acceptable to workplace
• emergency facility ER, ECU
• place to recover after surgery PAR, PACU
• registered bed patient IP
• care before surgery preop, pre-op
• patient pt
• well-developed, well-nourished WDWN
• bathroom privileges BRP

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Common Patient Care Abbreviations

• shortness of breath SOB
• treatment Tx, Tr
• temperature, pulse, T, P, respiration,
  blood pressure R, BP
• (vital signs) VS
• increase ?
• decrease ?
• degree or hour
• pound or number sign

(continued)
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Error Prone Abbreviations and Symbols

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

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Error Prone Abbreviations and Symbols
(continued)

• q. d every day
• mistaken for q.i.d when the period after the q
  is sloppily written to look like an i
• spell out daily
• q.o.d. every other day
• mistaken for q.d when the o is mistaken for a
  period
• spell out every other day

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Error Prone Abbreviations and Symbols
(continued)

• DC, D/C discharge, discontinue
• mistaken for discontinue when followed by
  medications prescribed at the time of discharge
• spell out discontinue or discharge
• gt, lt greater than, less than
• mistaken for each other
• spell out greater than or less than

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Error Prone Abbreviations and Symbols
(continued)

• AS, AD, AU left ear, right ear, both earsOS,
  OD, OU left eye, right eye, both eyes
• mistaken for each other
• spell out left ear, right eye, etc.
• SC or SQ subcutaneous
• mistaken for SL (sublingual) or 5 every
• spell out "subcutaneously or use sub-Q

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Pharmaceutical Abbreviations and Symbols

• Metric
• cc (cubic centimeter)
• cm (centimeter)
• g or gm (gram)
• kg (kilogram)
• L (liter)
• mg (milligram)
• ml or mL (milliliter) Note 1 cc 1 mL
• mm (millimeter)
• cu mm or mm3 (cubic millimeter)

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Pharmaceutical Abbreviations and Symbols
(continued)

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

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Medication Administration - Drug Forms

• Solid and Semisolid Forms
• Tablet (tab)
• Capsule (cap)
• Suppository (suppos)
• Liquid Forms
• Fluid
• Parenteral (ID, sub-Q, IM, IV)
• Cream, lotion, ointment
• Other delivery systems
• Transdermal
• Implant

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Parenteral Drug Administration
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The Prescription

• Physicians written direction for dispensing or
  administering a medication for a patient
• Must be written in a specific format
• Rx
• Symbol at beginning of prescription
• Stands for recipe

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Drug Names

• Chemical name assigned to drug at the time it
  is formulated
• Generic name the official, nonproprietary name
  given a drug
• Trade or brand the manufacturer's name for a
  drug

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Drug Names
(continued)

• For example
• Chemical name 1-3-(6,7-dihydro-1-ethyl-7-oxo-3-p
  ropyl-1H-pyrazolo4,3-
• pyrimidin-5-yl)-4-ethoxyphenylsulfonyl-4-methylp
  iperazine citrate
• Generic name sildenafil
• Trade or Brand name Viagra

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Sample Prescription
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Military Time
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Corrections

• Careful clarification of an error when making an
  entry in a medical record is essential
• Include
• Date
• The abbreviation corr
• Initials of person making corrections
• Do not use correction fluid!

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Proper Correction of a Medical Record