Medical Medical TerminologyTerminologyA Programmed Learning
Approach toA Programmed Learning Approach to the Language of Health
Care, 2 the Language of Health Care, 2nd nd Edition EditionChapter
2:Chapter 2:Health Care RecordsHealth Care Records2History and
Physical History and Physical (H&P)(H&P)Document of medical
history and Document of medical history and fndings from physical
examinationfndings from physical
examinationIncludesIncludes!u"#ecti$e information %
history!u"#ecti$e information % historyo"tained from patient
including o"tained from patient including his&her personal
perceptionshis&her personal perceptions'"#ecti$e information %
physical'"#ecti$e information % physicalfacts and o"ser$ations made
"y an facts and o"ser$ations made "y an examinerexaminer3History
(Hx)History (Hx)(ecord of the patient)s personal (ecord of the
patient)s personal medical history including past medical history
including past in#uries, illnesses, operations, in#uries,
illnesses, operations, defects, and ha"itsdefects, and
ha"itsIncludes 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 re$ie* of systemshistory and re$ie* of systems4History
(Hx) History (Hx) AbbreviationsAbbreviationsCCCCChief
ComplaintChief Complaint+rief description of *hy patient is see,ing
care+rief description of *hy patient is see,ing care
c/oc/ocomplains ofcomplains of-sed in descri"ing complaint -sed in
descri"ing complaintPIPI oror HPIHPIPresent Illness Present Illness
or or History of Present IllnessHistory of Present Illness.otation
of duration and se$erity of complaint .otation of duration and
se$erity of complaintHo* "ad is it/ Ho* long ha$e they had it/ Ho*
"ad is it/ Ho* long ha$e they had it/SxSx symptomsymptomE$idence of
illness that the patient reports E$idence of illness that the
patient reports5History (Hx) History (Hx)
AbbreviationsAbbreviationsPH PH or or PMHPMHPast History Past
History oror Past 0edical HistoryPast 0edical History.otation of
surgeries, in#uries, .otation of surgeries, in#uries, physical
defects, medications, physical defects, medications,
allergiesallergiesCH!CH!usual childhood diseasesusual childhood
diseases"#A"#Ano ,no*n allergiesno ,no*n allergies"#!A"#!A
no ,no*n drug allergiesno ,no*n drug allergies1continued2
1continued26History (Hx) History (Hx)
AbbreviationsAbbreviations$H$H
3amily History3amily History.otes a"out the state of health of
.otes a"out the state of health of immediate family
mem"ersimmediate family mem"ersExample 3H father, age 45,
mother,Example 3H father, age 45, mother, age 46, "rother, age 72,
all L89 age 46, "rother, age 72, all L89A&%A&%
ali$e and *ellali$e and *ell&&%&&%
li$ing and *ellli$ing and *ell1continued2 1continued27History
(Hx) History (Hx) AbbreviationsAbbreviationsSHSH!ocial
History!ocial History(ecreational interests, ho""ies, use
(ecreational interests, ho""ies, use of to"acco&drugsof
to"acco&drugs'H'H'ccupational History'ccupational History9or,
ha"its that may in$ol$e *or, 9or, ha"its that may in$ol$e *or,
related ris,srelated ris,s('S('S oror S(S((e$ie* of !ystems (e$ie*
of !ystems oror !ystems (e$ie*!ystems (e$ie*:uestions related to
function of the :uestions related to function of the "ody
systems"ody systems1continued2 1continued28Physical )xam (Px or
Physical )xam (Px or P))P))Document of physical Document of
physical examination of a patient including examination of a
patient including notations of positi$e and negati$e notations of
positi$e and negati$e fndingsfndingsIncludes results of diagnostic
testingIncludes results of diagnostic testing!ign % o"#ecti$e
e$idence of disease!ign % o"#ecti$e e$idence of disease9Physical
)xam Physical )xam AbbreviationsAbbreviationsH))"TH))"Thead, eyes,
ears, nose, head, eyes, ears, nose, and throatand
throatP)((&AP)((&Apupils e;ual, round, and pupils e;ual,
round, and reacti$e to light and reacti$e to light and
accommodationaccommodation"A!"A!no acute distressno acute
distress%"&%"&*ithin normal limits*ithin normal
limits10History and PhysicalHistory and PhysicalIm*ression (IMP)
Im*ression (IMP)!iagnosis (!x) !iagnosis (!x)Assessment (A)
Assessment (A)identifcation of a disease or condition
afteridentifcation of a disease or condition after e$aluation of
all su"#ecti$e and o"#ecti$ee$aluation of all su"#ecti$e and
o"#ecti$e information information(+le o+t ((/') (+le o+t ((/')aa
diferential diagnosis diferential diagnosis noted *hen one ornoted
*hen one or more diagnoses are suspect< re;uiresmore diagnoses
are suspect< re;uires further testing to $erify or eliminate
eachfurther testing to $erify or eliminate each possi"ility
possi"ility11History and PhysicalHistory and
PhysicalP&A",P&A",()C'MM)"!ATI'",()C'MM)"!ATI'",
oror!ISP'SITI'"!ISP'SITI'"outline of the treatment plan designed
outline of the treatment plan designed to remedy the patient)s
condition, to remedy the patient)s condition, *hich includes
instructions to the *hich includes instructions to the patient and
orders for medications, patient and orders for medications,
diagnostic tests, or therapiesdiagnostic tests, or
therapies1continued2 1continued212S'AP Progress "otesS'AP Progress
"otesProgress notes made after the initial Progress notes made
after the initial history and physical is recorded= >he history
and physical is recorded= >he letters represent the order in
*hich letters represent the order in *hich progress is
notedprogress is notedSSs+b-ectives+b-ective % % that *hich the
patient descri"es that *hich the patient
descri"es''ob-ectiveob-ective % % o"ser$a"le information, such
aso"ser$a"le information, such as test results, "lood pressure
readings, etc= test results, "lood pressure readings, etc=A A
assessmentassessment % % progress and e$aluation of theprogress and
e$aluation of the e?ecti$eness of the plan e?ecti$eness of the
planP P *lan*lan % % decision to proceed or alter strategy decision
to proceed or alter strategy13Common Hos*ital Common Hos*ital
(ecords(ecordsHistory and PhysicalHistory and PhysicalPhysician)s
ordersPhysician)s ordersDiagnostic tests&la"oratory
reportsDiagnostic tests&la"oratory reports.urse)s notes.urse)s
notesPhysician)s progress notesPhysician)s progress
notesConsultation reportConsultation report'perati$e
report'perati$e reportPathology reportPathology
reportAnesthesiologist)s reportAnesthesiologist)s
report14!iagnostic Imaging !iagnostic Imaging
ModalitiesModalitiesI'"I.I"/ IMA/I"/I'"I.I"/ IMA/I"/ A process that
changes the electrical A process that changes the electrical charge
of atoms *ith a possi"le e?ect on charge of atoms *ith a possi"le
e?ect on "ody cells< o$erexposure can ha$e "ody cells<
o$erexposure can ha$e harmful side e?ects, e=g=, cancerharmful side
e?ects, e=g=, cancer (ADI'@(APHA 1BC(AA2 (ADI'@(APHA
1BC(AA2C'0P->ED >'0'@(APHAC'0P->ED >'0'@(APHA or
orC'0P->ED ABIAL >'0'@(APHA C'0P->ED ABIAL
>'0'@(APHA.-CLEA( 0EDICI.E I0A@[email protected]( 0EDICI.E I0A@I.@ or
or(ADI'.-CLIDE '(@A. I0A@I.@ (ADI'.-CLIDE '(@A. I0A@I.@15!iagnostic
Imaging !iagnostic Imaging ModalitiesModalities"'"I'"I.I"/
IMA/I"/"'"I'"I.I"/ IMA/I"/ an imaging process that an imaging
process that presents no apparent ris, presents no apparent ris,
[email protected]>IC (E!'.A.CE I0A@I.@[email protected]>IC (E!'.A.CE
I0A@I.@!'.'@(APHA!'.'@(APHA1continued2 1continued216Common Terms
Common Terms (elated to !isease(elated to !iseaseacute $s=
chronicacute $s= chronic"enign $s= malignant"enign $s=
malignantlocaliDed $s= systemiclocaliDed $s= systemicexacer"ation
$s= remissionexacer"ation $s=
remissionprogressi$eprogressi$erecurrentrecurrentdegenerati$edegenerati$e17Common
Terms Common Terms (elated to !isease(elated to !iseasesymptom
1su"#ecti$e2symptom 1su"#ecti$e2sign 1o"#ecti$e2sign
1o"#ecti$e2diagnosis 1through ,no*ing2diagnosis 1through
,no*ing2syndrome 1running together2syndrome 1running
together2prognosis 1"efore ,no*ing2prognosis 1"efore
,no*ing2etiology 1study of cause2etiology 1study of
cause2idiopathic 1disease of indi$idual2idiopathic 1disease of
indi$idual2se;uelase;uela1continued2 1continued218Common Terms
Common Terms (elated to !isease(elated to !iseasegood $s=
malaisegood $s= malaisefe"rile $s= afe"rilefe"rile $s=
afe"rilemar,edmar,ede;ui$ocale;ui$ocalnoncontri"utorynoncontri"utoryunremar,a"leunremar,a"lemor"iditymor"iditymortalitymortality1continued2
1continued219Common Patient Care Common Patient Care
AbbreviationsAbbreviations-se only those accepta"le to -se only
those accepta"le to *or,place*or,placeemergency facilityemergency
facility)(, )C)(, )Cplace to reco$er after surgeryplace to reco$er
after surgeryPA(, PACPA(, PACregistered "ed patientregistered "ed
patientIPIPcare "efore surgerycare "efore surgery*reo*,
*re0o**reo*, *re0o*patientpatient*t*t*ellCde$eloped,
*ellCnourished*ellCde$eloped, *ellCnourished%!%"%!%""athroom
pri$ileges"athroom pri$ileges1(P1(P20Common Patient Care Common
Patient Care AbbreviationsAbbreviationsshortness of "reathshortness
of "reathS'1S'1treatmenttreatmentTx, TrTx, Trtemperature, pulse,
temperature, pulse, T, P, T, P, respiration, "lood pressure
respiration, "lood pressure(, (, 1P 21P 2
1$ital signs21$ital signs23S3S increase increase
decreasedecreasedegree or hourdegree or hourEEpound or num"er
signpound or num"er signFF1continued2 1continued221)rror Prone
)rror Prone Abbreviations and Abbreviations and
SymbolsSymbols0edical errors caused "y illegi"le *riting 0edical
errors caused "y illegi"le *riting and misinterpretations of
a""re$iations and misinterpretations of a""re$iations and sym"ols
ha$e led health care and sym"ols ha$e led health care agencies,
such as the Goint Commission on agencies, such as the Goint
Commission on Accreditation of Healthcare 'rganiDations
Accreditation of Healthcare 'rganiDations 1GCAH'2, to re;uire that
medical facilities 1GCAH'2, to re;uire that medical facilities
pu"lish lists of authoriDed a""re$iations pu"lish lists of
authoriDed a""re$iations for use "y all personnel, including a list
of for use "y all personnel, including a list of a""re$iations and
sym"ols that are a""re$iations and sym"ols that are
unaccepta"le=unaccepta"le=22)rror Prone )rror Prone Abbreviations
and Abbreviations and SymbolsSymbols45 d 45 d every dayevery
daymista,en for ;=i=d *hen the period mista,en for ;=i=d *hen the
period after the H;I is sloppily *ritten to after the H;I is
sloppily *ritten to loo, li,e an HiIloo, li,e an HiIspell out
HdailyIspell out HdailyI45o5d5 45o5d5 every other dayevery other
daymista,en for ;=d *hen the HoI is mista,en for ;=d *hen the HoI
is mista,en for a periodmista,en for a periodspell out He$ery other
dayIspell out He$ery other dayI1continued2 1continued223)rror Prone
)rror Prone Abbreviations and Abbreviations and SymbolsSymbols!C,
!/C !C, !/C discharge, discontin+edischarge, discontin+emista,en
for HdiscontinueI *hen follo*ed "ymista,en for HdiscontinueI *hen
follo*ed "y medications prescri"ed at the time ofmedications
prescri"ed at the time of discharge dischargespell out
HdiscontinueI or HdischargeIspell out HdiscontinueI or
HdischargeI6, 7 6, 7 greater than, less thangreater than, less
thanmista,en for each other mista,en for each otherspell out
Hgreater thanI or Hless thanIspell out Hgreater thanI or Hless
thanI1continued2 1continued224)rror Prone )rror Prone Abbreviations
and Abbreviations and SymbolsSymbolsAS, A!, Ale8t ear, right ear,
both AS, A!, Ale8t ear, right ear, both earsears'S, '!, ' le8t eye,
right eye, both 'S, '!, ' le8t eye, right eye, both
eyeseyesmista,en for each other mista,en for each otherspell out
Hleft ear,I Hright eye,I etc=spell out Hleft ear,I Hright eye,I
etc=SC SC or or S9 S9 s+bc+taneo+ss+bc+taneo+smista,en for !L
1su"lingual2 or H4 e$eryI mista,en for !L 1su"lingual2 or H4
e$eryIspell out Jsu"cutaneouslyH or use su"C:spell out
Jsu"cutaneouslyH or use su"C:1continued2
1continued225Pharmace+tical Pharmace+tical Abbreviations and
Abbreviations and SymbolsSymbols0etric0etriccc 1cu"ic centimeter2cc
1cu"ic centimeter2cm 1centimeter2cm 1centimeter2g g oror gm
1gram2gm 1gram2,g 1,ilogram2,g 1,ilogram2L 1liter2L 1liter2mg
1milligram2mg 1milligram2ml ml oror mL 1milliliter2 mL 1milliliter2
Note: Note: K cc L K mLK cc L K mLmm 1millimeter2mm 1millimeter2cu
mm cu mm or or mmmm77 1cu"ic millimeter21cu"ic
millimeter226Pharmace+tical Pharmace+tical Abbreviations and
Abbreviations and SymbolsSymbolsApothecaryApothecaryM oD 1Muid
ounce2M oD 1Muid ounce2gr 1grain2gr 1grain2gt 1drop2gt 1drop2gtt
1drops2gtt 1drops2dr 1dram2dr 1dram2oD 1ounce2oD 1ounce2l" or F
1pound2l" or F 1pound2;t 1;uart2;t 1;uart21continued2
1continued227Medication Medication Administration 0 !r+g
Administration 0 !r+g $orms$orms!olid and !emisolid 3orms!olid and
!emisolid 3orms>a"let 1ta"2 >a"let 1ta"2Capsule 1cap2 Capsule
1cap2!uppository 1suppos2 !uppository 1suppos2Li;uid 3ormsLi;uid
3orms3luid 3luidParenteral 1ID, su"C:, I0, IN2 Parenteral 1ID,
su"C:, I0, IN2Cream, lotion, ointment Cream, lotion, ointment'ther
deli$ery systems 'ther deli$ery systems>ransdermal
>ransdermalImplant Implant28Parenteral !r+g Parenteral !r+g
AdministrationAdministration29The Prescri*tionThe
Prescri*tionPhysician)s *ritten direction for Physician)s *ritten
direction for dispensing or administering a dispensing or
administering a medication for a patientmedication for a
patient0ust "e *ritten in a specifc 0ust "e *ritten in a specifc
formatformat(x(x!ym"ol at "eginning of prescription !ym"ol at
"eginning of prescription!tands for recipe !tands for recipe30!r+g
"ames!r+g "amesChemical nameChemical name % assigned to % assigned
to drug at the time it is formulateddrug at the time it is
formulated/eneric name/eneric name % the oOcial, % the oOcial,
nonproprietary name gi$en a nonproprietary name gi$en a
drugdrugTradeTrade or or brandbrand % the % the manufacturerPs name
for a drugmanufacturerPs name for a drug31!r+g "ames!r+g "ames3or
example3or exampleChemical name:Chemical name:
KCQ7C1R,SCdihydroCKCKCQ7C1R,SCdihydroCKCethylCSCoxoC7CpropylCKHCpyraDoloQ6,7CethylCSCoxoC7CpropylCKHCpyraDoloQ6,7CpyrimidinC4Cyl2C6CpyrimidinC4Cyl2C6CethoxyphenylTsulfonylTC6CethoxyphenylTsulfonylTC6CmethylpiperaDine
citratemethylpiperaDine citrate/eneric name:/eneric name:
sildenaflsildenaflTradeTrade or or 1rand name:1rand name:
NiagraNiagra1continued2 1continued232Sam*le Prescri*tionSam*le
Prescri*tion33Military TimeMilitary
Time34CorrectionsCorrectionsCareful clarifcation of an error
Careful clarifcation of an error *hen ma,ing an entry in a *hen
ma,ing an entry in a medical record is essentialmedical record is
essentialIncludeIncludeDateDate>he a""re$iation HcorrI>he
a""re$iation HcorrIInitials of person ma,ing correctionsInitials of
person ma,ing correctionsDo not use correction MuidUDo not use
correction MuidU35Pro*er Correction o8 a Pro*er Correction o8 a
Medical (ecordMedical (ecord