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The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx), physical examination (PE), consent forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]
This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes).This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology § List of abbreviations for those).
Department of Health: DOL: day of life DORV: double outlet right ventricle: DOS: date of service DOSS: docusate sodium; from the chemical name dioctyl sodium sulfosuccinate DP: dorsalis pedis: DPH: diphenylhydantoin: DPL: diagnostic peritoneal lavage: DPLD: diffuse parenchymal lung disease: DPM: Doctor of Podiatric Medicine: DPT: diphtheria ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...
Family history of glaucoma: FMH: Family medical history FOH: Family ocular history F/U: Follow up appointment GH: General health G(M)P: General (medical) practitioner HA: Headaches HARC: Harmonious abnormal retinal correspondence HM: Hand motion vision – state distance Hx: History IOL: Intra-ocular lens IOP: Intra-ocular pressure ISNT ...
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments"; Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; Social history: "an age-appropriate review of past and current activities".
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
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