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H & P
History and Physical: documentation of patient history and physical examination findings
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Hx
History: record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits
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Subjective Information:
- CC: Chief Complaint
- c/o: complains of: patient's description of what brought him or her to the doctor or hospital
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HPI (PI)
History of Present Illness (Present Illness): amplification of the chief complaint recording details of the duration and severity of the condition
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Sx
Symptom: subjective evidence (from the patient) that indicates an abnormality
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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
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UCHD
Usual Childhood Diseases: an abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood
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NKDA
No Known Drug Allergies
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FH
Family History: state of health of immediate family members
- - A & W: alive and well
- - L & W: living and well
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SH
Social History: a record of the patient's recreational interests, hobbies and the use of tobacco and drugs, including alcohol
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OH
Occupational History: a record of work habits that may involve work-related risks
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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
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PE (Px)
Physical Examination: documentation of a physical examination of a patient, including notations of positive and negative objective findings
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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
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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
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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
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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
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