Medical terminology ch 2 health care records

History and physical.

History

Subjective information from patient's personal statement about his or her medical history.  Includes information regardign past injuries, illnesses, operations, defects, and habits.

Chief Complaint

Usually brief and recorded in patients own words.

History of Present Illness

Duration and severity of complaint.

Symptoms

Subjective evidence of illness which indicates what patient is experiencing. 

Past Medical History

Includes a record of information about patient's past illnesses, starting with childhood, includes surgical operations, injuries, physcal defects, medications, and allergies.  UCHD ( usual childhood diseases ) is often used here to indicate that the patient had usual childhood diseases as a child.

Usual childhood diseases.

Indicates patient had usual childhood diseases as a child.

No Known Allergies

No Known Drug Allergies

Family History

State of health of Immediate family members.

Social History

Patient's recreational activities; hobbies, tobacco, alcohol, drug use.

Occupational History

Record of work habits that may involve health risks.

Review of Symptoms

A head to toe review of the function of all the body's systems.  This review makes it possible to evaluate other symptoms that may not have been mentioned.

Physical Examination

Physical examination of patient.  Objective information about patient gained from examination or testing.

Objective evidence of disease.

Head, Eyes, Ears, Nose, Throat

Pupils Equal, Round and Reactive to Light and Accommodation.

No Acute Distress

Within Normal Limits

assessment

impression

diagnosis

Rule Out

When more than one diagnosis is possible, attempts are made to rule out diagnoses to identify the main diagnosis.

Plan / recommendation / disposition

Strategies are outlined to remedy the patient's condition, including instructions to the patient and orders for medications, diagnostic tests, or therapies.

A History and Physical that is done prior to a patient undergoing surgery to be certain the patient is healthy enough for surgery.

Method of documenting a patient's progress, the letters represent the order in which progress is noted as each complaint or problem is addressed.

• S - Subjective - what the patient describes
• O - Objective - observable information; test results, blood pressure readings, etc.
• A - Assessment - patient's progress and evaluation of plan's effectiveness, newfound problems or diagnoses are also noted here
• P - Plan - decision to proceed or to alter the plan strategy

Alive and well

Living and well

Complains of

Impression

Objective information

Information gained by observation, examination, or testing.  This is different and separate from information the patient gives.

Subjective

The patient describing, in their own words, their problem, symptoms, complaint.

Present Illness

Documentation of patient's care.

List of directives for care prescribed by the doctor who is attending to the patient.

Chronicle care through the patient's stay.

Chronicle care through the patient's stay.

Report made by consulting physician in difficult cases.

a detailed account of the operation, including the method of incision, technique, instruments used, types of suture, method of closure, patient's responses during procedure and at time of recovery.

Report covering anesthesia details, including drugs used, dosage and time given, patient's vital status throughout procedure.

Form signed by the patient showing that he or she has been advised of the risks and benefits of the proposed treatment as well as any alternatives.

Reports noting additional procedures and therapies, including diagnostic tests and pathology reports.

Summary of patient's hospital care, including date of admission, diagnosis, course of treatment, final diagnosis, and date of discharge.

A process that changes the electrical charge of atoms and has a possible effect on body cells.

Category of imaging techniques.

• Radiography ( xray )
• Computed Tomography ( CT )
• Nuclear medicine.

• Magnetic Resonance Imaging ( MRI )
• Sonography / ultrasonography ( US )

An xray image.

Radiologic procedure which uses a machine ( called a scanner ) to examine a body site by taking a series of cross-sectional ( tomographic ) x-ray films in a full-circle rotation.  A computer then calculates and converts the separate images into a 3-dimensional picture.

Radioactive isotopes ( also called radionuclides ) or a substance tagged with a radioactive compounds which emit gamma rays are ingested ( swallowed ) by or injected into a patient.  A gamma camera detects the emitted radiation and produces an image of the emitted radiation.  This technique is useful for determining the size, shape, location and function of body organs such as the brain, lungs, bones, and heart.

A large magnet surrounds the patient which temporarily alters the alignment of Hydrogen atoms in the body, altering their alignment, then turning off and letting them realign.  The energy given off by this process is picked up by a scanner and converted into an image.  This method is useful for examining soft tissues, joints, brain, and spinal cord.

Magnetic resonance technology used to study blood flow.

High frequency sound waves are bounced off internal structures, received by the transducer, then converted to an image to provide live images of the inside of a patient.  This technology is useful for viewing abdomen, reproductive organs, thyroid, parathyroid, and cardiovascular system.

Substances which are swallowed, injected, introduced by IV or enema, which can move to or through parts of the body and will show up on imaging devices.

Process of recording

Nuclear medicine