Recording skills
Charting , recording, documentation
Who has access to pts medical information?
Government agencies : Medicare/Medicaid
Insurance agencies
Accreditation teams
AMA
Against medical advice
DC
Discharge or discontinue
DNR
Do not resuscitate
H&P
History & physical
HPI
History of present illness
H/O
History of
NKDA
No known drug allergies
PCP
Primary care physicians
A&O
Alert and oriented
WNL
Within normal limits
RF
Risk factors
Sx
Symptoms
Dx
Diagnosis