History and Physical

-documentation of patient history and physical examination findings

History

-record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits

Chief Complaint

complains of

-patient's description of what brought him or her to the doctor or hospital; it is usually brief and is often documented in the patient's own words indicated within quotes

History of Present Illness (Present Illness)

-amplification of the chief complaint recording details of the duration and severity of the condition (how long has the patient had the complaint and how bad it is)

Symptom

-subjective evidence (from the patient) that indicates an abnormality

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

Usual Childhood Diseases

-an abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood (e.g., measles, chickenpox, mumps)

Family History

-state of health of family members

Social History

-a record of the patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol

Occupational History

-a record of work habits that may involve work-related risks

Review of Systems (Systems Review)

-a documentation of the patient's response to questions organized by a head-to-toe review of the funtion of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned)

Physical Examination

-documentation of a physical examination of a patient, including notations of positive and negative objective findings

Assessment

-identification of a disease or condition after evaluation of the patient's hsitory, symptoms, signs, and results of laboratory tests and diagnostic procedures

Rule Out

-used to indicate a differential diagnosis when one or more diagnoses are suspect;l each possible diagnosis is outlined and either verified or eliminated after further testing is performed

Plan

(also referred to as recommendation or disposition)

-outline of the treatment plan designed to remedy the patient's condition, which inculdes instructions to the patient, orders for medications, diagnostic tests, or therapies

ER

intensive care unit

post-op/postop

discharge

-if before the numeral, it means number

-if after the numeral, it means pound

a feeling of unwellness, often the first indication of illness

fl oz

by mouth

before meals

after meals