Medical Terminology (PHT 102) - The Medical Record

Medical Terminology (PHT 102) Handout

• Section 2: The Medical Record
  • The history and physical is a cornerstone of patient care, documenting medical history and physical exam findings.
  • It's typically the first record generated when a patient seeks care.
  • Subjective information, such as chief complaint, history of present illness, past medical, family, social, and occupational histories are recorded.
  • A review of systems is also documented to uncover potential diseases.
  • Objective information, obtained through examination and tests, is documented as signs, or evidence of disease.
  • Diagnostic tests are performed or ordered for further evaluation.
  • The impression or diagnosis is made after evaluating all information, including tests and findings.
  • Differential diagnoses (R/O) are considered when multiple possible diagnoses exist.
  • Further tests are needed to eliminate possibilities and confirm the final diagnosis.
  • A provider's plan (recommendation or disposition) outlines strategies to address the patient's condition.
  • Further progress notes are added as care progresses.
  • A preoperative history and physical report may be required for surgery.

Abbreviations and Definitions

• H&P: History and Physical
• Hx: History
• Subjective Information: Information obtained from the patient; their perspective.
• CC: Chief Complaint
• c/o: Complains of
• HPI (PI): History of Present Illness
• Sx: Symptom
• PMH (PH): Past Medical History
• UCHD: Usual Childhood Diseases
• NKA/NKDA: No known allergies
• FH: Family History
• SH: Social History
• OH: Occupational History
• ROS (SR): Review of Systems
• PE (Px): Physical Examination
• HEENT: Head, Eyes, Ears, Nose, and Throat.
• NAD: No acute distress
• PERRLA: Pupils equal, round, and reactive to light and accommodation (eye exam)
• WNL: Within Normal Limits.
• Dx: Diagnosis
• IMP: Impression
• A: Assessment
• R/O: Rule Out

Types of Medical Facilities

• CCU: Coronary Care Unit
• ECU: Emergency Care Unit
• ER: Emergency Room
• ICU: Intensive Care Unit
• IP: Inpatient (patient in hospital)
• OP: Outpatient (patient coming to hospital for test or treatment)
• OR: Operating Room
• PACU: Postanesthetic Care Unit
• PAR: Postanesthetic Recovery
• Post-op/postop: Postoperative (after surgery)
• Pre-op/preop: Preoperative (before surgery)
• L, R: Left, Right
• pt: Patient
• RRR: Regular Rate and Rhythm
• SOB: Shortness of breath
• Tr: Treatment
• VS: Vital Signs
• T: Temperature
• P: Pulse
• R: Respiration
• BP: Blood Pressure
• Ht: Height
• Wt: Weight
• WDWN: Well-developed and well-nourished
• y.o.: Years old

Additional Terms & Abbreviations

• (This section contains a multitude of terms and abbreviations related to medical conditions, diagnoses, and procedures. It is best to review them individually to maximize comprehension.)

• Acute: Sharp, severe, short-term condition

• Chronic: Persistent, long-term condition

• Benign: Mild, non-cancerous, harmless

• Malignant: Harmful, cancerous, aggressive

• Degeneration: Gradual deterioration of normal cells

• Degenerative disease: Disease with cell deterioration

• Diagnosis: Identifying a disease based on symptoms and tests

• Etiology: Cause of a disease

• Exacerbation: Worsening of a disease's symptoms

• Remission: Temporary absence of symptoms

Explore the essential components of the medical record in this quiz, focusing on subjective and objective information. Understand how history and physical exams contribute to patient care, diagnosis, and differential diagnoses. Test your knowledge of this fundamental aspect of medical terminology in the PHT 102 course.