P A T I E N T • A R E A
H-PT words referring to patient Patient complained of diarrhea
H-PTAREA anatomical area Lesion is located at the base of the lung.
H-PTDESCR occupation, nationality, traits Patient is affable. Patient is a carpenter.
H-PTFUNC physiological function Appetite poor. Patient has range of motion of the left shoulder.
H-PTLOC anatomical location relation Fracture radiates from left shoulder.
H-PTMEAS anatomical measure Weight 127 lbs. Normal cardiac size.
H-PTPALP palpated body part No liver.
H-PTPART body part Patient has metacarpal stiffness.
H-PTSPEC specimen type Right knee shavings.
H-PTVERB verb with patient subject Patient suffered a myocardial infarction.
T E S T / E X A M • A R E A
H-OBSERVE verbs of observation No ataxia was detected on finger-to-nose testing
H-TXCLIN clinical exam, action Palpation of abdomen revealed tenderness. Kenig's sign positive.
H-TXPROC examination procedure MRI shows a grade 1 spinal listhesis.
H-TXSPEC test of specimen Blood chemistries showed electrolytes normal.
H-TXVAR test variable Acetone is normal. WBC 53.
T R E A T M E N T • A R E A
H-DEVMED medical devices Pt has a pacemaker. Pt uses a walker.
H-INST hospitals, clinics, physicians, staff Pt seen in ER. Pt will see a cardiologist.
H-TTCOMP complementary treatments Improved on bedrest.
H-TTGEN general medical management Pt returned to hospital. Discharge of patient from ZZZ hospital.
H-TTMED treatment by medication Doctor prescribed ampicillin.
H-TTMODE mode of administration intramuscular
H-TTSURG surgical procedure Excision of cataract in left eye.
H-POST support class for prefix morpheme post- Postprandial discomfort
H-TMBEG beginning Treatment was begun. Fever developed.
H-TMEND termination Fever disappeared. Medication was discontinued.
H-TMLOC location in time During the previous week.
H-TMDUR duration persistent cough. Episode of meningitis.
H-TMPREP time preposition After last week... During admission...
H-TMREP repetition Headache recurring... Second admission...
F I N D I N G S • A R E A
H-AMT amount or degree Full range of motion. Severe pain.
* H-BEH behavior
H-CHANGE indication of change alterations in management.
H-CHANGE-LESS decrease Ampicillin tapered from 500 mg to 300 mg qid.
H-CHANGE-MORE increase a rise in his Creatinine to 2.3.
weight gain.
H-CHANGE-SAME no change Cardiac silhouette remains within normal limits. Neurologic diagnoses are static.
H-DIAG diagnosis Patient has glaucoma.
H-INDIC disease indicator word Patient complained of tenderness in joints.
H-NORMAL non-problematical Temperature normal. Growth and development — within normal limits
H-ORG organism CSF showed H. Influenzae type B.
H-RESP patient response His blood gas improved on 35% oxygen.
H-TXRES test/exam result word Positive Kernig's. Gram stain negative.
H-DESCR descriptive information A punctate dark lesion.
H-DIET name of foods, dietary prescriptions Allergic to tomatoes.
E V I D E N T I A L • A R E A
H-NEG negation of finding Patient refused medication. Patient never had headaches.
H-MODAL uncertainty of finding; event has not yet occurred Rule out meningitis. Doctor advised surgery.
C O N N E C T I V E • A R E A
H-BECONN classifier verb Treatment consisted of ampicillin.
H-CONN connects 2 information units Fever caused the headache.
H-SHOW connects test and result Echo revealed apical akinesis.
H-VTEST lab or measurement verbs HCT ranged from 24 to 35.
O T H E R • S E M A N T I C • C L A S S E S
H-AGE life stage adult, adolescence, years old, age
VBE verb 'be'
BEREP be replacer verbs She becomes drowsy.
VDO verb 'do'
VHAVE verb 'have'
H-FAMILY family member or friend Brother also has sickle cell disease.
H-GEOGR geographical names Pt currently lives in San Francisco.
H-ETHNIC racial or ethnic background white male... African American female...
H-RECORD patient record terms Review of health records showed PPD of 1972 was also positive.
H-TESTVIEW angles or positions of imaging lateral, axial, PA
H-TRANSP general term that gets classes from its modifiers a tonic, clonic type of convulsion. The ist of medications... The state of the disease...