Császár, J. – Jámbor, M. – Barta, A. – Végh, A. – Fogarasi, K. (2024): How to Use History and Physical Examination (H&P) in teaching English medical terminology and documentation skills in Hungary? Porta Lingua. 2024/1. 37-46

DOI: https://doi.org/10.48040/PL.2024.1.4

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Absztrakt

History and Physical (H&P) is a genre for clinical documentation in Anglo-Saxon countries, which serves the detailed recording of patient history and physical examinations to facilitate medical decision-making. It is used in any medical field either as a template or as a digitalized text following a set of rules. In teaching Medical English and Terminology, it can be applied to demonstrate the use of terms in context and lexico-grammatical patterns typical of English-speaking countries. At Semmelweis University, we have started to involve this genre for LSP and Terminology instruction, especially examples created at emergency departments (ED), because these include extensive vocabulary related to all organ systems. These medical records (MR) also serve a didactic purpose as they contain general information on the diagnosed problems. In our case study, we compared ten Hungarian and ten American ED medical records to reveal generic, structural, and terminological discrepancies. We found differences in structure, terminology, abbreviations, and contents, which students should be made aware of. Clinicians involved in our pilot research suggested the introduction of didactic ED documentation also for the instruction of Hungarian students and residents as this genre might be a gap-filling tool for practicing concise documentation skills in emergency care.

Keywords: H&P, medical documentation, emergency care, teaching Medical English, Medical Terminology, genre analysis