Medical Record: Care Documentation

  1. H & P
    History and Physical: documentation of patient history and physical examination findings
  2. Hx
    History: record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits
  3. Subjective Information:
    • CC: Chief Complaint
    • c/o: complains of: patient's description of what brought him or her to the doctor or hospital
  4. HPI (PI)
    History of Present Illness (Present Illness): amplification of the chief complaint recording details of the duration and severity of the condition
  5. Sx
    Symptom: subjective evidence (from the patient) that indicates an abnormality
  6. PMH (PH)
    Past Medical History (Past History): a record of information about the patient's past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies
  7. UCHD
    Usual Childhood Diseases: an abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood
  8. NKA
    No Known Allergies
  9. NKDA
    No Known Drug Allergies
  10. FH
    Family History: state of health of immediate family members

    • - A & W: alive and well
    • - L & W: living and well
  11. SH
    Social History: a record of the patient's recreational interests, hobbies and the use of tobacco and drugs, including alcohol
  12. OH
    Occupational History: a record of work habits that may involve work-related risks
  13. ROS (SR)
    Review of Systems (Systems Review): a documentation of the patient's response to questions organized by a head-to-toe review of the function of all body systems
  14. PE (Px)
    Physical Examination: documentation of a physical examination of a patient, including notations of positive and negative objective findings
  15. Objective Information:
    • HEENT: head, eyes, ears, nose, throat
    • NAD: no acute distress, no appreciables disease
    • PERRLA: pupils equal, round, and reactive to light and accommodation
    • WNL: within normal limits
  16. Dx
  17. IMP
  18. A
    Assessment: identification of a disease or condition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures
  19. R/O
    Rule Out: used to indicate a differential diagnosis when one or more diagnoses are suspect; each possible diagnosis is outlined and either verified or eliminated after further testing is performed
  20. P
    Plan (AKA Recommendation or Disposition): outline of the treatment plan designed to remedy the patient's condition, which includes

    • - instructions to the patient
    • - orders for medications
    • - diagnostic tests
    • - therapies
Card Set
Medical Record: Care Documentation
Chapter 4: Medical Record: Care Documentation