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EVOLVE.ELSEVIER EHR

Ch.5 Vocab

TermDefinition
Acute Condition An illness or injury that is episodic (ex.seizures), has a sudden onset, is of limited duration and generally responds well to prompt medical attention
Anthropemetric Measurments Measurements of height, weight, and size used to compare to the relative proportions of the human body in health and illness
Cheif Complaint (CC) A brief statement of the problem, condition, or symptoms that prompted the patient to seek medical care. Sometimes referred to as a chief concern
Chronic condition An illness that persists for a prolonged time (3+ months)such as Type 2 diabete, emphysema,
E-Visit An evaluation and management serviceprovided by a member of a current patient's healthcare team across safe and secure nline systems
High-Alert Medications A medication that poses a heightened risk od injury or death when administered improperly
History of Present Illness (HPI) Details about duration, time , location, severity, context, associated signs and symptoms, quality, and modifying factors related to the patient's illness
Medication Reconcilliation The process of comparing the medication list in a patients EHR with the patient's self-report of the medications they have been taking
Objective Objective (as in S.O.A.P. notes) Readily seen, percieved, or measured by the clinician, not only by the patient
PFSH An abbreviation for past (medical)l family, and social history
Review of Systems (ROS) An organized inventory of each organ system, completed as part of the initial patientt interview to pinpoint any unusual findings in the patient's history
Speech Recognition A technology that converts speech into text
Subjective (As in S.O.A.P. Notes) Percieved only by the patient and not evident to or measurable by the clinician
Created by: user-1773160
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