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IHMO Workbook Chapter 4
44 cards·by gr1m89
Comprehensive, level of history or examination
C
Chief Complaint
CC
chief complaint, history of present illness, examination, details, drugs and dosages,
assessment, return visit information or referral
CHEDDAR
current procedural terminology
CPT
detailed, level of history or examination
D
diagnosis
dx, Dx
emergency department or emergency room
ED or ER
electronic health record
EHR
evaluation and management
E/M service
electronic medical record
EMR
expanded problem focused, level of history or examination
EPF
facsmile
fax
family history
FH
high complexity, medical decision making
HC
health information management
HIM
human immunodeficiency virus
HIV
history of present illness
HPI
intensive care unit
ICU
impression
imp
low complexity, medical decision making
LC
left lower quadrant
LLQ
left upper quadrant
LUQ
question
MC
natural language processing
NLP
nonphysician practitioner
NPP
primary care physician
PCP
physical examination
PE or PX
probleem focussend, level of history or examination
PF
past history, family or social history
PFSH
past history
PH
present illness
PI
problem-oriented record, system
POR
respiratory care unit
RCU
right lower quadrant
RLQ
rule out
R/O
review of systems
ROS
straightforward, medical decision making
SF
right upper quadrant
RUQ
social history
SH
subjective, objective, assessment, plan; style
SOAP
source-oriented record; system
SOR
type of service
TOS
within normal limits
WNL
I list of all staff members names job titles signatures and their initials is know as
signature log.