Medical History and Physical Information by mka57435


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									      Chapter 4

The Medical Record
          History and Physical H & P
               Figure 4.1 page 58

 Document of medical history and findings from
  physical examination

    Subjective information — History
     obtained from patient including his/her personal
    Objective Information — Physical
     facts and observations made by an examiner
                    History (Hx)

 Record of the patient’s 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
            History (Hx) Abbreviations

CC Chief Complaint or c/o complains of
Brief description of why patient is seeking care

PI or HPI Present Illness/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
         History (Hx) Abbreviations

PH, PMH Past History, Past Medical History
Notation of surgeries, injuries, physical defects,
medications, allergies

UCHD        usual childhood diseases

NKA         no known allergies

NKDA        no known drug allergies
          History (Hx) Abbreviations

FH     Family History
Notes about the state of health of immediate family

Example: FH: father, age 58, mother, age 54,
brother, age 32, all L&W

A&W     alive and well

L&W     living and well
           History (Hx) Abbreviations

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, Systems Review
questions related to function of the body systems

HEENT head, eyes, ears, nose, throat
          Physical Exam (Px or PE)

 Document of physical examination of a patient
  including notations of positive and negative

  Includes: results of diagnostic testing

  Sign — objective evidence of disease
        Physical Exam Abbreviations

HEENT     head, eyes, ears, nose, throat

PERRLA pupils equal, round and reactive to
       light and accommodation

NAD       no acute distress, no appreciable disease

WNL       within normal limits
               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
           History and Physical


outline of the treatment plan designed to
remedy the patient’s condition, which includes
instructions to the patient, orders for
medications, diagnostic tests, or therapies
Problem Oriented Medical Record (POMR)

 Health record with focus on patient’s problem
 Information organized for access at a glance
 Documents thought processes of provider
 Consists of four sections:
      Database
      Problem list
      Initial plan
      Progress notes
Problem Oriented Medical Record (POMR)
                   SOAP 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
    Common Hospital Records

   History and Physical
   Physician’s orders
   Diagnostic tests/laboratory reports
   Nurse’s notes
   Physician’s progress notes
   Consultation Report
   Operative Report
   Pathology report
   Anesthesiologist’s report
  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
patient                          pt
well developed, well nourished   WDWN
bathroom privileges              BRP
     Common Patient Care Abbreviations

difficulty breathing                 SOB
treatment                            Tx, Tr
temperature, pulse,                  T, P, R, BP =
respiration, blood pressure          VS or vital signs
increase                             
decrease                             
degree or hour                       °
pound or number sign                 #
    Error Prone Abbreviations and Symbols

Medical errors caused by illegible entries and
misinterpretations 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 those unacceptable.
  Error Prone Abbreviations and Symbols

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”
 Error Prone Abbreviations and Symbols

DC, D/C      discharge, discontinue
mistaken for “discontinue” when followed by medications
prescribed at the time of discharge

spell out “discontinue” or “discharge”

>, <         greater than, less than
mistaken for each other

spell out
 Error Prone Abbreviations and Symbols

AS, AD, AU left ear, right ear, both ears
OS, OD, OU left eye, right eye, both eyes
mistaken for each other

spell out

SC or SQ          subcutaneous
mistaken for SL (sublingual), or “5 every”.

spell out "subcutaneously“ or use Sub-Q
        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


  Diagnostic Imaging Modalities

presents no apparent risk

Common Terms Related to Disease

     acute vs chronic
     benign vs malignant
     localized vs systemic
     exacerbation vs remission
Common Terms Related to Disease

  symptom (subjective)
  sign (objective)
  diagnosis (through knowing)
  syndrome (running together)
  prognosis (before knowing)
  etiology (study of cause)
  idiopathic (disease of individual)
Common Terms Related to Disease

        good vs malaise
        febrile vs afebrile
Pharmaceutical Abbreviations and Symbols

      Metric
           cc (cubic centimeter)
           cm (centimeter)
           g or gm (gram)
           kg (kilogram)
           L (liter)
           mg (milligram)
           ml, ML (milliliter) Note: 1 cc = 1 mL
           mm (millimeter)
           cu, mm (cubic millimeter)
Pharmaceutical Abbreviations and Symbols

            Apothecary
                 fl oz (fluid ounce)
                 gr (grain)
                 gt (drop)
                 gtt (drops)
                 dr (dram)
                 oz (ounce)
                 lb or # (pound)
                 qt (quart)
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
Parenteral Drug Administration
                The Prescription

 Physician’s 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
                 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 Names

For example:

Chemical name: 1-[[3-(6,7-dihydro-1-
4-methylpiperazine citrate

Generic name: sildenafil

Trade or Brand name: Viagra
Sample Prescription
Military Time

 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!
Proper Correction of a Medical Record

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