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What are the 3 types of dispositions? - correct answers Discharge, Admit, Transfer. What does HPI stand for? - correct answers history of present illness What does ROS stand for? - correct answers review of systems The HPI and ROS are considered what type of information? - correct answers subjective The physical exam is what type of information? - correct answers objective If a physician told you a patient's abdomen was non tender, where would you document this? - correct answers PE What section focuses directly on the chief complaint? - correct answers HPI If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? - correct answers CAD Name an example of something you may write in the Social Hx portion of the chart. - correct answers smokes 1 pack/day Name an example of something you may write in the Family Hx portion of the chart. - correct answers Mother had Hx of CAD at age 46 What are the abbreviations for the following past medical history terms? Hypertension Stroke Diabetes Heart Attack High Cholesterol - correct answers HTN CVA (cerebrovascular accident) DM MI HLD