Chapter 2 Introduction to Health Records PDF

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These notes cover Chapter 2 of Medical Terminology with Prof. Jody Morris....

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Medical Terminology 11 September 2017 Chapter 2: Intro to Health Records The SOAP Method: Subjective: ❖ The first part of the note is the subjective part. It is subject to how a patient experiences and personally describes his or her problem as well as personal and family medical histories. Put simply, it is the problem in the patient's own words. The subjective data includes the duration of the problem, the quality of the problem, and any exacerbating or relieving factors for that problem. ➢ These are the problems that the patient states/he she has. “I feel like…” ➢ Those problems are then translated into medical terms. ■ This is so that you can correctly communicate the problems to all health care providers ❖ General Subjective Terms: ➢ Symptom ➢ Noncontributory ➢ Acute (less than three months) vs. Chronic (more than three months) ➢ Abrupt ➢ Progressive V.S. Exacerbation (Remission) ➢ Febrile (Fever) vs. Afebrile (Without Fever “a”) Objective: ❖ The next step in the investigative process includes collecting objective data. Objective data comprise the patient's physical exam, any laboratory findings, and imaging studies performed at the visit. Can physically see, hear, and smell these symptoms. ❖ General Objective Terms: ➢ Things that are seen: alert (conscious or unconscious) , oriented (can be conscious, but they are able to tell you their name, date, can count, etc) ➢ Things that are felt: palpation (lightly touching them from head to toe, feel any abnormalities) ➢ Things that are heard: Auscultation (take stethoscope, listen to heart, bowel/digestive sounds), percussion (cup hand, place over abdominal region, listen for sounds of dullness or fullness (Empty or full bowels) ➢ Descriptions of what is observed: Unremarkable (no differences from the other side), marked (different compared to the other side, ex. Right leg is sprained)

Assessment:

❖ Upon gathering all the pertinent information, the healthcare provider formulate a logical analysis this is known as the assessment. An assessment could be a diagnosis, and identification of a problem, or a list of possibilities for the diagnosis which is known as a differential diagnosis. ❖ General Objective Terms: ➢ Impression: What you think it’s wrong ➢ Diagnosis: What is actually wrong ➢ Differential Diagnosis: Almost positive you know what’s wrong, but not ready to make diagnosis just yet. ➢ Etiology (cause of the disease) vs. Idiopathic (No known cause) ➢ Benign (not cancerous) vs. Malignant (cancerous) ➢ Remission: No longer showing symptoms, but still have the disease. ➢ Morbidity: Risk of being sick or diseased. ➢ Mortality: Risk for dying. ➢ Prognosis: Chance of getting better/what’s going to happen next. ➢ Localized (one area) vs. systemic/generalized (Over a large area or body system) ➢ Pathogen: Organism that causes the disease. ➢ Lesion: Diseased tissue ➢ Sequelae: Result of disease or injury; for example, paralysis can be the sequelae of spinal cord injury. General Plan: ❖ The provider then formulates a plan or a course of action consistent with his or her assessment. The plan could be a treatment with medicine or procedure. It could also consist of collecting for their dated help arrive at a more accurate diagnosis. ❖ General Plan Terms: ➢ Disposition: Where they are going after they receive treatments ➢ Observation: Observe the patient, see if there is any changes ➢ Reassurance: Try to offer this to the patient to keep them calm, or if they don’t understand you can explain it. ➢ Supportive Care: Something that you do to help the patient feel better. ➢ Palliative: Helping the patient feel better, but the prognosis is grim. Like Hospice. ❖ The process of collecting subject of history, gathering objective data, formulating an assessment, and developing an action plan is if he didn't every healthcare visit across all disciplines of medicine. It is a baseline of thought and medicine. Consequently, healthcare records reflect this thought process. ❖ Upon admittance to the hospital, patients must provide a medical history and receive a physical exam. Afterward, the attending medical professional writes a detailed admission summary. Detailed admission summaries are usually thorough notes that are very heavy

on the subjective and objective parts, because the idea of the summary is to assemble all the facts in one place to help direct the entire hospital course. Body Planes and Orientation: ❖ Anatomical Position: Facing forward, hands forward, feet forward ❖ Proximal (closer to the point of attachment) vs. Distal (further) – Refers to the attachment to the trunk; used when describing the upper extremities (arms) and lower extremities (legs) ❖ Lateral vs. Medial – describes the relationship to the center ❖ Anterior (front) /Antral/Ventral – all mean front when referring to the human ❖ Posterior (back) /Dorsal – all mean back when referring to the human ❖ Cranial vs. Caudal – cranial means head, caudal means tail; used when describing areas of the trunk, head, and neck ❖ Superior (Closer to the Head) vs. Inferior (Closer to the ground) ❖ Supine: Facing upwards ❖ Prone: Lying on their stomach (face down) ❖ Ipsilateral: Same side ❖ Contralateral: Opposite Side ➢ The image shows that the brain controls the opposite limb, or has a contralateral control. ❖ Unilateral means one side; Bilateral means two sides ❖ Dorsum: Back of the hand ❖ Palmer: Front of the hand ❖ Dorsum: Top of the foot ❖ Plantar: Portion of foot that I stand on, walk on ❖ Sagittal Plane: Divides the body in right or left portions ➢ Mid Sagittal Plane: Equal right and left hand sides/portions ❖ Coronal or Frontal Plane: Divides the body into anterior and posterior sides (front and back). ❖ Transverse Plane: Divides the body into superior and inferior (top and bottom). Abdominopelvic Regions and Quadrants: ❖ Hypochondriac Region: Anatomical ❖ Epigastric Region: Top of the stomach ❖ Right and Left Lumbar: Lower Back ❖ Hypogastric Region: Below stomach region ❖ Right and Left Iliac Region: Below the hip ❖ Right upper Quadrant (RUQ) ❖ Left Upper Quadrant (LUQ) ❖ Right Lower Quadrant (RLQ) ❖ Left Lower Quadrant (LLQ)

Areas of the Health Care Facility: ❖ Pre-Op: Where the family members wish the patient good luck and it's before they enter the OR. ❖ OR: Operating Room, where the surgery takes place ❖ PACU: Post Anesthetic Room ❖ Post-Op: After anesthesia ❖ ICU: Intensive Care Unit: CCU (Critical Care Unit-NOT ON THE TEST), SICU (Surgical Intensive Care Unit), PICU (Pediatric Intensive Care Unit), NICU (Neonatal Intensive Care Unit) ❖ ER: Emergency Room ❖ ED: Emergency Depart ❖ ECU: Emergency Care Unit ❖ L&D: Labor and Delivery Common on Health Records: ❖ VS (vital signs) are made up of the HR (HEART RATE), RR (RESPIRATORY RATE), BP (BLOOD PRESSURE), and T (TEMPERATURE). ❖ I/O: Input/Output ❖ Dx: Diagnosis ❖ DDx: Differential Diagnosis ❖ Tx: Treatment ❖ Rx: Prescription ❖ Hx (History): PMHx (Past Medical History; FHx (Family History)) ❖ H&P: History and Physical ❖ CC: Chief Complaint ❖ HPI: History of Present Illness ❖ ROS: Review of Systems ❖ PE: Physical Exam ❖ PCP: Primary Care Provider/Physician ❖ Prn: As needed ❖ QID: Four times daily ❖ QD: Daily ❖ AC: Before meals ❖ TID: Three Times Daily ❖ BID: Two Times Daily ❖ PC: After meals ❖ QHS: At night Types of Health Records:

Sections of a Health

Description

Record Chief complaint

The main reason for the patient's visit

History of

The story of the patient's problem

present illness Review of systems

Description of individual body systems in order to discover any symptoms not directly related to the main problem

Past medical history

Other significant past illnesses, like high blood pressure, asthma, or diabetes

Past surgical

Any of the patient's past surgeries

history Family history

Any significant illnesses that run in the patient's family

Social history

A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

❖ Upon admittance to the hospital, patients must provide a medical history and receive a physical exam. Afterward, the attending medical professional writes a detailed admission summary. Detailed admission summaries are usually thorough notes that are very heavy on the subjective and objective parts, because the idea of the summary is to assemble all the facts in one place to help direct the entire hospital course. ❖ The assessment, which usually describes the thought process behind a patient's diagnosis and a list of possible causes for the patient's problem, is known as a differential diagnosis. Common Terms on Health Records: ❖ general subjective terms Term acute ah-KYOOT

Definition it just started recently or is a sharp, severe symptom

chronic

it has been going on for a while now

KRAH-nik exacerbation

it is getting worse

ek-SAS-er-BAY -shun abrupt

all of a sudden

ah-BRUPT febrile

to have a fever

FEH-brail afebrile

to not have a fever

AY-FEH-brail malaise

not feeling well

mah-LAYZ progressive

more and more each day

proh-GREH-siv symptom

something a patient feels

SIM-tom noncontributor

not related to this specific problem

y NON-kon-TRIByoo-TOH-re e lethargic lah-THAR-jik genetic/heredit

a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick it runs in the family

ary jih-NEH-tik, hah-REH-di h-TEH-ree

general objective terms

Term alert

Definition able to answer questions; responsive; interactive

ah-LERT oriented

being aware of who he or she is, where he or she is, and the current time; a

OR-ee-EN-ted

patient who is aware of all three is “oriented × 3”

marked

it really stands out

MARKT unremarkabl

another way of saying normal

e un-ree-MARKah-bul auscultation

to listen

aws-kul-TAYshun percussion

to hit something and listen to the resulting sound or feel for the resulting

per-KUH-shun

vibration; drums are a percussion instrument

palpation

to feel

pal-PAY-shun

general assessment terms Term impression

Definition another way of saying assessment

im-PREH-shun

diagnosis DAI-ag-NOH-sis

what the health care professional thinks the patient has

differential

a list of conditions the patient may have based on the symptoms

diagnosis

exhibited and the results of the exam

dih-fer-EN-shal DAI-ag-NOH-sis

benign

safe

beh-NAIN

malignant

dangerous; a problem

mah-LIG-nant

degeneration

to be getting worse

dee-jin-er-AY-shun

etiology

the cause

ee-tee-AW-loh-jee

remission

to get better or improve; most often used when discussing cancer; remission  does not mean cure

reh-MIH-shun

idiopathic

no known specific cause; it just happens

ih-dee-oh-PA-thik

localized LOH-kah-LAIZD

stays in a certain part of the body

systemic/generalize

all over the body (or most of it)

d sih-STEM-ik, jin-er-ah- LAIZD

morbidity

the risk for being sick

mor-BID-ih-tee

mortality

the risk for dying

mor-TA-lih-tee

prognosis

the chances for things getting better or worse

prawg-NOH-sis

occult

hidden

ah-KULT

pathogen

the organism that causes the problem

PATH-oh-jin

lesion

diseased tissue

LEE-shun

recurrent

to have again

ree-KUR-ent

sequelae

a problem resulting from a disease or injury

seh-KWEL-ah

pending

waiting for

PEN-ding

general plan terms Term

disposition

Definition

what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU,

dis-poh-ZIH-

normal hospital bed)

shun

discharge

literally, to unload ; it has two meanings:

DIS-charj

1. to send home (to unload the patient from the health care setting to home) 2. fluid coming out of a part of the body (your body unloading a fluid)

prophylaxis

preventive treatment

PROH-fuh-L AK-sis

palliative

treating the symptoms, but not actually getting rid of the cause

PA-lee-ah-ti v

observation

watch, keep an eye on

OB-zer-VAY -shun

reassuranc

to tell the patient that the problem is not serious or dangerous

e ree-ah-SHU R-ants

supportive

to treat the symptoms and make the patient feel better

care suh-POR-tiv kehr

sterile

extremely clean, germ-free conditions; especially important during medical procedures and surgery

STEH-ril

opposites Term proximal

Definition closer in to the center proximal and approximate come from the same word and mean close

PRAWK-sih-mal

distal

farther away from the center distal and distant come from the same word and mean far

DIH-stal

lateral

out to the side

LA-ter-al

think of a quarterback lateraling a football to a running back

medial

toward the middle

MEE-dee-al

like the median of a highway

ventral/antral/

the front the word ventral  means stomach

anterior VEN-tral/AN-tral/an-TI H-ree-or

dorsal/posterior

the back

DOR-sal/

a dorsal fin on a shark is on its back

pohs-TEER-ee-or

cranial

toward the top

KRAY-nee-al

caudal

toward the bottom

KOW-dal

from Latin, for tail

superior

above

soo-PIH-ree-or

inferior

below

in-FIH-ree-or

prone

lying down on belly

PROHN

supine

lying down on back

SOO-pain

contralateral KON-trah-LA-ter-al

opposite side

ipsilateral

same side

IP-sih-LA-ter-al

unilateral

one side

YOO-nih-LA-ter-al

bilateral BAI-LA-ter-al

both sides

dorsum

the top of the hand or foot

DOR-sum

plantar

the sole of the foot

PLAN-tar

palmar PAL-mar

the palm of the hand

Body Planes Another way of looking at the body is through the three dimensions: right to left (sagittal), front to back (coronal), and top to bottom (transverse). This is especially important in radiology. For instance, a CT scan is actually a series of layered images along one of these dimensions.

body planes Term

Definition

sagittal

divides the body in slices right to left

SA-jih-tal

sagitta is Latin for arrow ; think of this as dividing the body in half, as if someone shot an arrow through it.

coronal

divides the body into slices from front to back

kah-ROH-

corona is Latin for crown ; this plane divides the body in half from the top of the

nal

head down

transvers

divides the body from top to bottom

e

tranz-VER S

Abbreviatons:

health care facility abbreviations

Abbreviatio

Definition

n

CCU

coronary care unit

ECU

emergency care unit

ER

emergency room

ED

emergency department

ICU

intensive care unit

PICU

pediatric intensive care unit

NICU

neonatal intensive care unit

SICU

surgical intensive care unit

PACU

postanesthesia care unit

L&D

labor and delivery

OR

operating room

post-op

after surgery

pre-op

before surgery

abbreviations common on health records Abbreviatio

Definition

n

VS

vital signs

T

temperature

BP

blood pressure

HR

heart rate

RR

respiratory rate

Ht

height

Wt

weight

BMI

body mass index (measurement of body fat based on height and weight)

I/O

intake/output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)

Dx

diagnosis

DDx

differential diagnosis

Tx

treatment

Rx

prescription

H&P

history and physical

Hx

history

CC

chief complaint (the main reason for the visit)

HPI

history of present illness (the story of the symptoms)

ROS

review of systems (anything else not directly related to the chief complaint)

PMHx

past medical history

FHx

family history

PE

physical exam

Pt

patient

y/o

years old

h/o

history of

PCP

primary care provider

f/u

follow-up

abbreviations used for symptoms or exam findings Abbreviatio

Definition

n

SOB

while it may mean something outside of medicine, here, it means shortness  of breath Note: Because of the negative non-medical meaning, it has been suggested that SOB should be replaced by other abbreviations like SOA (shortness of air).

PERRLA

pupils are equal, round, and reactive to light and accommodation

NAD

no acute distress (the patient does not display any intense symptoms)

RRR

regular rate and rhythm (description of a normal heart on exam)

CTA

clear to auscultation (description of normal sounding lungs)

WDWN

well developed, well nourished (the patient is growing or has grown appropriately and does not appear to be malnourished)

A&O

alert and oriented (the patient can answer questions and is aware of what's going on)

WNL

within normal limits

NOS

not otherwise specified

NEC

not elsewhere classified Note: NOS and NEC are catch-alls for di...