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H/O: history of ... HOB: head of bed (usually followed by number of degrees of elevation, e.g., HOB 10°) HOCM: hypertrophic obstructive cardiomyopathy: HONK: hyperosmolar nonketotic state HOPI: History of present illness: H&P: history and physical examination (which very often are considered as a pair) HPA: hypothalamic-pituitary-adrenal axis ...
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.
h., h hour: hora: qhs, h.s., hs at bedtime or half strength quaque hora somni ii two tablets duos doses iii three tablets trēs doses n.p.o., npo, NPO nothing by mouth / not by oral administration: nil per os o.d., od, OD right eye. once a day (United Kingdom) oculus dexter omne in die o.s., os, OS left eye: oculus sinister o.u., ou, OU both eyes
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).
Pronunciation follows convention outside the medical field, in which acronyms are generally pronounced as if they were a word (JAMA, SIDS), initialisms are generally pronounced as individual letters (DNA, SSRI), and abbreviations generally use the expansion (soln. = "solution", sup. = "superior").
For example, sharing information about someone on the street with an obvious medical condition such as an amputation is not restricted by U.S. law. However, obtaining information about the amputation exclusively from a protected source, such as from an electronic medical record, would breach HIPAA regulations. Business Associates
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.