Chapter 2 - Introduction to Health Records Questions and Answers Latest Update 2025/2026
EHR - Answers Electric Health Record
subjective data - Answers What the patient says/reports
objective data - Answers What the tests/exam reveals
assessment - Answers The analysis of the subjective and objective information; performed by
the health care provider.
plan - Answers Course of action for the patient
SOAP - Answers Acronym for different types of information documented by the health care
providers (subjective, objective, assessment, plan)
Chief Complaint (CC) - Answers the main reason for the patient's visit
History or Present Illness (HPI) - Answers The story of the patients problem
Review of Systems (ROS) - Answers Description of individual body systems in order to discover
any symptoms not directly related to the main problem
Past Medical History (PMH) - Answers Other significant past illnesses, high blood pressure,
asthma or diabetes
Past Surgical History (PSH) - Answers any of the patient's past surgeries
Family History (FH) - Answers Any significant illnesses that run in the patients family
Social History (SH) - Answers A record of habits like smoking, drinking, drug abuse, and sexual
practices that can impact health
Palpation - Answers feeling a structure with the hands
Auscultation - Answers to listen (usually with a stethoscope)
Supine - Answers To lie on back with chest facing up
unremarkable - Answers another way of saying normal
Prone - Answers To lie face down
Transverse plane - Answers Divides the body in half top to bottom
Saggital plane - Answers Divides the body in half left to right
Cornal plane - Answers Divides the body in half front to back
, Pre-op - Answers Before surgery
OR - Answers Operating Room
PACU - Answers Postanesthesia care unit , the critical care area where patients are taken after
surgery for monitoring
Post-Op - Answers After surgery
ICU - Answers Intensive Care Unit
CCU - Answers coronary care unit or critical care unit
SICU - Answers Surgical Intensive Care Unit
PICU - Answers Pediatric Intensive Care Unit
NICU - Answers Neonatal Intensive Care Unit
ER - Answers Emergency Room
ED - Answers emergency department or erectile dysfunction
ECU - Answers Emergency Care Unit
L&D - Answers Labor and delivery
H&P - Answers History and Physical
CC - Answers chief complaint
HPI - Answers History of Present Illness
ROS - Answers Review of Systems
PE - Answers physical exam, pulmonary embolism
PCP - Answers Primary Care Provider
Clinic note - Answers Can be handwritten, dictated, or electronic and can involve circling words
Consult note - Answers Note in form of letter to primary care provider. Usually a specialist (i.e:
Neurologist or Cardiologist)
Emergency department note - Answers Mixture of any completed disgnostic tests, the patient
assessment, and plan for patient that unfolds over time.
Admission summary - Answers Thorough notes that are very heavy on the subjective and
objective parts, because the summary assembles all facts in one place to help direct the
EHR - Answers Electric Health Record
subjective data - Answers What the patient says/reports
objective data - Answers What the tests/exam reveals
assessment - Answers The analysis of the subjective and objective information; performed by
the health care provider.
plan - Answers Course of action for the patient
SOAP - Answers Acronym for different types of information documented by the health care
providers (subjective, objective, assessment, plan)
Chief Complaint (CC) - Answers the main reason for the patient's visit
History or Present Illness (HPI) - Answers The story of the patients problem
Review of Systems (ROS) - Answers Description of individual body systems in order to discover
any symptoms not directly related to the main problem
Past Medical History (PMH) - Answers Other significant past illnesses, high blood pressure,
asthma or diabetes
Past Surgical History (PSH) - Answers any of the patient's past surgeries
Family History (FH) - Answers Any significant illnesses that run in the patients family
Social History (SH) - Answers A record of habits like smoking, drinking, drug abuse, and sexual
practices that can impact health
Palpation - Answers feeling a structure with the hands
Auscultation - Answers to listen (usually with a stethoscope)
Supine - Answers To lie on back with chest facing up
unremarkable - Answers another way of saying normal
Prone - Answers To lie face down
Transverse plane - Answers Divides the body in half top to bottom
Saggital plane - Answers Divides the body in half left to right
Cornal plane - Answers Divides the body in half front to back
, Pre-op - Answers Before surgery
OR - Answers Operating Room
PACU - Answers Postanesthesia care unit , the critical care area where patients are taken after
surgery for monitoring
Post-Op - Answers After surgery
ICU - Answers Intensive Care Unit
CCU - Answers coronary care unit or critical care unit
SICU - Answers Surgical Intensive Care Unit
PICU - Answers Pediatric Intensive Care Unit
NICU - Answers Neonatal Intensive Care Unit
ER - Answers Emergency Room
ED - Answers emergency department or erectile dysfunction
ECU - Answers Emergency Care Unit
L&D - Answers Labor and delivery
H&P - Answers History and Physical
CC - Answers chief complaint
HPI - Answers History of Present Illness
ROS - Answers Review of Systems
PE - Answers physical exam, pulmonary embolism
PCP - Answers Primary Care Provider
Clinic note - Answers Can be handwritten, dictated, or electronic and can involve circling words
Consult note - Answers Note in form of letter to primary care provider. Usually a specialist (i.e:
Neurologist or Cardiologist)
Emergency department note - Answers Mixture of any completed disgnostic tests, the patient
assessment, and plan for patient that unfolds over time.
Admission summary - Answers Thorough notes that are very heavy on the subjective and
objective parts, because the summary assembles all facts in one place to help direct the
