Transcript The Medical Record

Chapter 4
The Medical Record
History and Physical H & P
Figure 4.1 page 58
 Document of medical history and findings from
physical examination
Includes:
 Subjective information — History
obtained from patient including his/her personal
perceptions
 Objective Information — Physical
facts and observations made by an examiner
History (Hx)
 Record of the patient’s 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
History (Hx) Abbreviations
CC Chief Complaint or c/o complains of
Brief description of why patient is seeking care
PI or HPI Present Illness/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
History (Hx) Abbreviations
(continued)
PH, PMH Past History, Past Medical History
Notation of surgeries, injuries, physical defects,
medications, allergies
UCHD
usual childhood diseases
NKA
no known allergies
NKDA
no known drug allergies
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 L&W
A&W
alive and well
L&W
living and well
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, Systems Review
questions related to function of the body systems
HEENT head, eyes, ears, nose, throat
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
Physical Exam Abbreviations
HEENT
head, eyes, ears, nose, throat
PERRLA pupils equal, round and reactive to
light and accommodation
NAD
no acute distress, no appreciable disease
WNL
within normal limits
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
History and Physical
(continued)
PLAN,
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, or therapies
Problem Oriented Medical Record (POMR)
 Health record with focus on patient’s problem
 Information organized for access at a glance
 Documents thought processes of provider
 Consists of four sections:
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Database
Problem list
Initial plan
Progress notes
Problem Oriented Medical Record (POMR)
(continued)
SOAP 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
Common Hospital Records
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History and Physical
Physician’s orders
Diagnostic tests/laboratory reports
Nurse’s notes
Physician’s progress notes
Consultation Report
Operative Report
Pathology report
Anesthesiologist’s report
Common Patient Care Abbreviations
Use only those acceptable to workplace
emergency facility
place to recover after surgery
registered bed patient
care before surgery
patient
well developed, well nourished
bathroom privileges
ER, ECU
PAR, PACU
IP
preop
pt
WDWN
BRP
Common Patient Care Abbreviations
(continued)
difficulty breathing
SOB
treatment
Tx, Tr
temperature, pulse,
respiration, blood pressure
T, P, R, BP =
VS or vital signs
increase

decrease

degree or hour
°
pound or number sign
#
Error Prone Abbreviations and Symbols
Medical errors caused by illegible entries and
misinterpretations 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 those unacceptable.
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”
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”
>, <
greater than, less than
mistaken for each other
spell out
Error Prone Abbreviations and Symbols
(continued)
AS, AD, AU left ear, right ear, both ears
OS, OD, OU left eye, right eye, both eyes
mistaken for each other
spell out
SC or SQ
subcutaneous
mistaken for SL (sublingual), or “5 every”.
spell out "subcutaneously“ or use Sub-Q
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
Diagnostic Imaging Modalities
(continued)
NON-IONIZING IMAGING a process that
presents no apparent risk
 MAGNETIC RESONANCE IMAGING
 SONOGRAPHY
Common Terms Related to Disease
acute vs chronic
benign vs malignant
localized vs systemic
exacerbation vs remission
progressive
recurrent
degenerative
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
Common Terms Related to Disease
(continued)
good vs malaise
febrile vs afebrile
gross
marked
equivocal
noncontributory
unremarkable
morbidity
mortality
Pharmaceutical Abbreviations and Symbols
 Metric
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cc (cubic centimeter)
cm (centimeter)
g or gm (gram)
kg (kilogram)
L (liter)
mg (milligram)
ml, ML (milliliter) Note: 1 cc = 1 mL
mm (millimeter)
cu, mm (cubic millimeter)
Pharmaceutical Abbreviations and Symbols
(continued)
 Apothecary
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fl oz (fluid ounce)
gr (grain)
gt (drop)
gtt (drops)
dr (dram)
oz (ounce)
lb or # (pound)
qt (quart)
Medication Administration — Drug Forms
 Solid and Semisolid Forms
 Tablet (tab)
 Capsule (cap)
 Suppository (suppos)
 Liquid Forms
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Fluid
Parenteral (ID, Sub-Q, IM, IV)
Cream, lotion, ointment
Other delivery systems
 Transdermal
 Implant
Parenteral Drug Administration
The Prescription
 Physician’s 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
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
Drug Names
(continued)
For example:
Chemical name: 1-[[3-(6,7-dihydro-1methyl-7-oxo-3-propyl-1H-pyrazolo[4,3pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]4-methylpiperazine citrate
Generic name: sildenafil
Trade or Brand name: Viagra
Sample Prescription
Military Time
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!
Proper Correction of a Medical Record