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Medical Terminology

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Medical Terminology A Programmed Learning Approach to the Language of Health Care, 2nd Edition Chapter 2: Health Care Records – PowerPoint PPT presentation

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Title: Medical Terminology


1
Medical Terminology
  • A Programmed Learning Approach to the Language of
    Health Care, 2nd Edition

Chapter 2Health Care Records
2
History and Physical (HP)
  • Document of medical history and findings from
    physical examination
  • Includes
  • Subjective information historyobtained from
    patient including his/her personal perceptions
  • Objective information physicalfacts and
    observations made by an examiner

3
History (Hx)
  • Record of the patients 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

4
History (Hx) Abbreviations
  • CC Chief Complaint
  • Brief description of why patient is seeking care
  • c/o complains of
  • Used in describing complaint
  • PI or HPI Present Illness or
  • 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

5
History (Hx) Abbreviations
(continued)
  • PH or PMH Past History or
  • Past Medical History
  • Notation of surgeries, injuries, physical
    defects, medications, allergies
  • UCHD usual childhood diseases
  • NKA no known allergies
  • NKDA no known drug allergies

6
History (Hx) Abbreviations
(continued)
  • FH Family History
  • Notes about the state of health of immediate
    family members
  • Example FH father, age 58, mother, age 54,
    brother, age 32, all LW
  • AW alive and well
  • LW living and well

7
History (Hx) Abbreviations
(continued)
  • 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 or Systems
    Review
  • Questions related to function of the body systems

8
Physical Exam (Px or PE)
  • Document of physical examination of a patient
    including notations of positive and negative
    findings
  • Includes results of diagnostic testing
  • Sign objective evidence of disease

9
Physical Exam Abbreviations
  • HEENT head, eyes, ears, nose, and throat
  • PERRLA pupils equal, round, and reactive to light
    and accommodation
  • NAD no acute distress
  • WNL within normal limits

10
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

11
History and Physical
(continued)
  • PLAN,RECOMMENDATION,
  • orDISPOSITION
  • outline of the treatment plan designed to remedy
    the patients condition, which includes
    instructions to the patient and orders for
    medications, diagnostic tests, or therapies

12
SOAP Progress 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

13
Common Hospital Records
  • History and Physical
  • Physicians orders
  • Diagnostic tests/laboratory reports
  • Nurses notes
  • Physicians progress notes
  • Consultation report
  • Operative report
  • Pathology report
  • Anesthesiologists report

14
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
  • RADIOGRAPHY (X-RAY)
  • COMPUTED TOMOGRAPHY or COMPUTED AXIAL
    TOMOGRAPHY
  • NUCLEAR MEDICINE IMAGING or RADIONUCLIDE ORGAN
    IMAGING

15
Diagnostic Imaging Modalities
(continued)
  • NONIONIZING IMAGING
  • an imaging process that presents no apparent
    risk
  • MAGNETIC RESONANCE IMAGING
  • SONOGRAPHY

16
Common Terms Related to Disease
  • acute vs. chronic
  • benign vs. malignant
  • localized vs. systemic
  • exacerbation vs. remission
  • progressive
  • recurrent
  • degenerative

17
Common Terms Related to Disease
(continued)
  • symptom (subjective)
  • sign (objective)
  • diagnosis (through knowing)
  • syndrome (running together)
  • prognosis (before knowing)
  • etiology (study of cause)
  • idiopathic (disease of individual)
  • sequela

18
Common Terms Related to Disease
(continued)
  • good vs. malaise
  • febrile vs. afebrile
  • marked
  • equivocal
  • noncontributory
  • unremarkable
  • morbidity
  • mortality

19
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, pre-op
  • patient pt
  • well-developed, well-nourished WDWN
  • bathroom privileges BRP

20
Common Patient Care Abbreviations
  • shortness of breath SOB
  • treatment Tx, Tr
  • temperature, pulse, T, P, respiration,
    blood pressure R, BP
  • (vital signs) VS
  • increase ?
  • decrease ?
  • degree or hour
  • pound or number sign

(continued)
21
Error Prone Abbreviations and Symbols
  • Medical errors caused by illegible writing and
    misinterpretations of abbreviations and symbols
    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 abbreviations and symbols that are
    unacceptable.

22
Error Prone Abbreviations and Symbols
(continued)
  • 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

23
Error Prone Abbreviations and Symbols
(continued)
  • DC, D/C discharge, discontinue
  • mistaken for discontinue when followed by
    medications prescribed at the time of discharge
  • spell out discontinue or discharge
  • gt, lt greater than, less than
  • mistaken for each other
  • spell out greater than or less than

24
Error Prone Abbreviations and Symbols
(continued)
  • AS, AD, AU left ear, right ear, both earsOS,
    OD, OU left eye, right eye, both eyes
  • mistaken for each other
  • spell out left ear, right eye, etc.
  • SC or SQ subcutaneous
  • mistaken for SL (sublingual) or 5 every
  • spell out "subcutaneously or use sub-Q

25
Pharmaceutical Abbreviations and Symbols
  • Metric
  • cc (cubic centimeter)
  • cm (centimeter)
  • g or gm (gram)
  • kg (kilogram)
  • L (liter)
  • mg (milligram)
  • ml or mL (milliliter) Note 1 cc 1 mL
  • mm (millimeter)
  • cu mm or mm3 (cubic millimeter)

26
Pharmaceutical Abbreviations and Symbols
(continued)
  • Apothecary
  • fl oz (fluid ounce)
  • gr (grain)
  • gt (drop)
  • gtt (drops)
  • dr (dram)
  • oz (ounce)
  • lb or (pound)
  • qt (quart)

27
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

28
Parenteral Drug Administration
29
The Prescription
  • Physicians 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

30
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

31
Drug Names
(continued)
  • For example
  • Chemical name 1-3-(6,7-dihydro-1-ethyl-7-oxo-3-p
    ropyl-1H-pyrazolo4,3-
  • pyrimidin-5-yl)-4-ethoxyphenylsulfonyl-4-methylp
    iperazine citrate
  • Generic name sildenafil
  • Trade or Brand name Viagra

32
Sample Prescription
33
Military Time
34
Corrections
  • 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!

35
Proper Correction of a Medical Record
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