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Medical Terminology: Medical Records & Documentation Part 2
This deck covers key medical terminology related to medical records and documentation, including definitions and explanations of common terms and abbreviations used in healthcare settings.
Define: HPI (History of Present Illness)
A detailed account of the patient's current health issue, including the timeline and nature of symptoms. The HPI revealed that the patient had been experiencing headaches for the past month.
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Key Terms
Term
Definition
Define: HPI (History of Present Illness)
A detailed account of the patient's current health issue, including the timeline and nature of symptoms. The HPI revealed that the patient had been ex...
Define: Vital Signs
Measurements that provide essential information about a patient's basic bodily functions, including heart rate, blood pressure, temperature, and respi...
Define: Physical Exam (PE)
A systematic examination of a patient's body to assess their health and detect any medical conditions. The doctor performed a Physical Exam (PE) to ch...
Define: Impression
The clinician's initial interpretation of the patient's condition based on the examination findings. The Impression suggested that the patient may hav...
Define: Follow-up
A subsequent appointment or check-in to monitor a patient's progress after treatment or intervention. The patient was scheduled for a Follow-up visit ...
Define: Intervention
An action taken to improve a patient's health or manage their condition, often part of a treatment plan. The Intervention included physical therapy to...
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| Term | Definition |
|---|---|
Define: HPI (History of Present Illness) | A detailed account of the patient's current health issue, including the timeline and nature of symptoms. The HPI revealed that the patient had been experiencing headaches for the past month. |
Define: Vital Signs | Measurements that provide essential information about a patient's basic bodily functions, including heart rate, blood pressure, temperature, and respiratory rate. The nurse recorded the Vital Signs to assess the patient's health status. |
Define: Physical Exam (PE) | A systematic examination of a patient's body to assess their health and detect any medical conditions. The doctor performed a Physical Exam (PE) to check for any abnormalities. |
Define: Impression | The clinician's initial interpretation of the patient's condition based on the examination findings. The Impression suggested that the patient may have an upper respiratory infection. |
Define: Follow-up | A subsequent appointment or check-in to monitor a patient's progress after treatment or intervention. The patient was scheduled for a Follow-up visit in one month. |
Define: Intervention | An action taken to improve a patient's health or manage their condition, often part of a treatment plan. The Intervention included physical therapy to aid in the patient's recovery. |
Define: Assessment Findings | The results obtained from various evaluations conducted during a patient's examination, used to inform diagnosis and treatment. The Assessment Findings indicated that the patient had a sprained ankle. |
Define: Clinical Judgment | The healthcare provider's ability to assess and make decisions regarding a patient's care based on their knowledge and experience. The physician's Clinical Judgment led to the diagnosis of a rare condition. |
Define: Referral | The process of directing a patient to another healthcare provider for specialized care or treatment. The doctor made a Referral to a cardiologist for further evaluation. |
Define: BP (Blood Pressure) | The force of blood against the walls of the arteries, measured in millimeters of mercury (mmHg). The patient's BP was recorded as 120/80 mmHg during the examination. |
Define: HR (Heart Rate) | The number of times the heart beats per minute, an important indicator of cardiovascular health. The patient's HR was elevated at 110 beats per minute due to anxiety. |
Define: RR (Respiratory Rate) | The number of breaths taken per minute, used to assess a patient's respiratory function. The nurse noted that the patient's RR was 22 breaths per minute, indicating mild distress. |
Define: O2 Sat (Oxygen Saturation) | The percentage of hemoglobin in the blood that is saturated with oxygen, usually measured with a pulse oximeter. The patient's O2 Sat was measured at 95%, indicating adequate oxygenation. |
Define: WNL (Within Normal Limits) | A term used to indicate that a patient's test results or physical examination findings fall within the established normal range. The lab results were reported as WNL, suggesting no immediate concerns. |
Define: PRN (As Needed) | A medical abbreviation indicating that a medication or treatment should be administered only when necessary. The patient was prescribed pain medication PRN for discomfort. |
Define: NPO (Nothing by Mouth) | A medical instruction indicating that a patient should not eat or drink anything for a specified period. The patient was placed NPO before the scheduled surgery. |
Define: PO (By Mouth) | A term used to indicate that a medication or treatment should be administered orally. The doctor prescribed the medication to be taken PO twice daily. |
Define: IV (Intravenous) | A method of delivering fluids, medications, or nutrients directly into a patient's bloodstream through a vein. The patient received hydration via an IV during their hospital stay. |
Define: IM (Intramuscular) | A route of medication administration where the drug is injected directly into a muscle. The vaccine was administered IM in the deltoid muscle. |
Define: BID (Twice a Day) | A medical abbreviation indicating that a medication should be taken two times per day. The patient was instructed to take the antibiotic BID for seven days. |
Define: TID (Three Times a Day) | A medical abbreviation indicating that a medication should be taken three times per day. The doctor prescribed the medication to be taken TID with meals. |
Define: QID (Four Times a Day) | A medical abbreviation indicating that a medication should be taken four times per day. The patient was advised to take the medication QID for optimal effectiveness. |
Define: STAT (Immediately) | A medical term used to indicate that something needs to be done without delay. The nurse was instructed to obtain the lab results STAT due to the patient's condition. |
Define: Dx (Diagnosis) | The identification of a disease or condition based on the evaluation of a patient's symptoms and medical history. The Dx was confirmed after reviewing the test results. |
Define: Tx (Treatment) | The management and care provided to a patient for the purpose of combating a disease or condition. The Tx plan included medication and physical therapy. |