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Terms in this set (767)
Chief Complaint Definition The reason why the patient came to see the
physician.
Chief Complaint Abbreviation CC
History of Present Illness HPI
Abbreviation
History of Present Illness Definition This is an explanation of the CC to determine the
onset of the illness; associated symptoms; what the
patient has done to treat the condition, etc.
, Past, Family and Social History PFSH
Abbreviation
Past Medical History Definition Includes all health problems, major illnesses,
surgeries the patient has had, current medications
complete with reasons for taking them, and
allergies.
Family History Definition Summary of health problems of siblings, parents,
and other blood relatives that could alert the
physician to hereditary and/or familial disease.
Social History Definition Includes marital status, occupation, educational
attainment, hobbies, use of alcohol, tobacco,
drugs, and lifestyles.
Review of Systems Abbreviation ROS
Review of Systems Definition This is an orderly and systematic check of each
organ and system of the body by questions. Both
positive and pertinent negative findings are
documented.
3 Body Processes Necessary for life Body Temperature, Respiration, Heart Function
are:
4 Vital Signs of Body Function are: Temperature, Pulse, Respiration, Blood Pressure