question

-assessment -patient's progress and evaluation of the plan's effectiveness; any newfound problem or diagnosis is also noted here -identification of a disease or condition is recorded here

answer

A

question

-alive and well; living and well

answer

A&W; L&W

question

-chief complaint -reason for seeking medical care

answer

CC

question

-complains of

answer

c/o

question

-diagnosis -identification of a disease or condition is recorded here

answer

Dx

question

-family history -state of health of immediate family members (father, mother, and siblings)

answer

FH

question

-head, eyes, ears, nose, and throat

answer

HEENT

question

-history and physical

answer

H&P

question

-history of present illness; present illness -details of the complaint noting duration and severity

answer

HPI; PI

question

-history

answer

Hx

question

-impression -identification of a disease or condition is recorded here

answer

IMP

question

-no acute distress

answer

NAD

question

-no known drug allergies

answer

NKDA

question

-objective information -observable information (ex: test results, blood pressure readings, etc.)

answer

O

question

-occupational history -work habits that may involve health risks

answer

OH

question

-plan (also recommendation, disposition) -decision to proceed or to alter the plan strategy

answer

P

question

-physical examination

answer

PE; Px

question

-pupils equal, round, and reactive to light accommodation

answer

PERRLA

question

-past history; past medical history

answer

PH; PMH

question

-rule out

answer

R/O

question

-review of systems; system review -review of the function of all body systems; makes it possible to evaluate other symptoms that may not have been mentioned

answer

ROS; SR

question

-subjective information -that which the patient describes

answer

S

question

-social history -patient's recreational interests

answer

SH

question

-symptom -subjective evidence of illness

answer

Sx

question

-usual childhood diseases

answer

UCHD

question

-within normal limits

answer

WNL

question

-subjective, objective, assessment, plan

answer

SOAP method

question

-when the diagnosis is uncertain -possible conditions that require further investigation, often through diagnostic tests and procedures, in order to rule out each suspected diagnosis and to verify the final diagnosis

answer

differential diagnosis

question

-objective evidence of disease including swelling, skin color changes, visible response to pain, deformation, and abnormal vital signs, etc.

answer

signs

question

-a current H&P report before admitting a patient to the hospital for surgery

answer

preoperative H&P

question

-also referred to as radiographers

answer

radiologic technologists

question

-high blood pressure -essential (primary): no specific medical cause can be found to explain a patient's condition -secondary: is a result of another condition, such as kidney disease -persistant hypertension is a risk factor for strokes, heart attack, heart failure, and arterial aneurysm and a leading cause of chronic renal failure

answer

hypertension

question

-often the first document entered into the patient's hospital record

answer

history and physical

question

-list the directives for care prescribed by the doctor attending to the patient

answer

physician's orders

question

-chronicle the care throughout the patient's stay

answer

nurse's & physician's progress notes

question

-filed after a specialist examines the patient

answer

consultation report

question

-narrative report after surgery filed by the primary surgeon

answer

operative report

question

-the anesthesiologist, who is in change of life support during surgery, files a report which covers the anesthesia details, including the drugs used, the dose and time given, and monitoring the patient's vital signs throughout the procedure

answer

anesthesiologist's report

question

-must be signed by the patient to show that he/she has been advised of the risks and benefits of the proposed treatment as well as any alternatives

answer

informed consent

question

-note any additional procedures and therapies, including diagnostic test and pathology reports

answer

ancillary reports

question

-final hospital document, recorded at the time of discharge, it is a summary of the patient's hospital care, including the date of admission, preliminary diagnoses, diagnostic tests, course of treatment, final diagnoses, and date of discharge

answer

discharge summary (clinical resume, clinical summary, discharge abstract)

question

-ear nose and throat specialist

answer

ENT

question

-joint commission of accreditation of healthcare organizations

answer

JCAHO

question

-right ear, left ear, both ears -mistaken as OD, OS, OU (right eye, left eye, both eyes) -spell out right ear, left ear, both ears

answer

*AD, AS, AU

question

-right eye, left eye, both eyes -mistaken as AD, AS, AU (right ear, left ear, both ears) -spell out right eye, left eye, both eyes

answer

*OD, OS, OU

question

-cubic centimeter -mistaken as units -use the metric equivalent mL

answer

*cc

question

-discharge, discontinue -mistaken for "discontinue" when followed by medications prescribed at the time of discharge -spell out discharge, discharge

answer

*DC, D/C

question

-bedtime -mistaken as "half strength" -spell out bedtime

answer

*h.s.

question

-every day -mistaken as q.i.d. when the period after the "q" is written sloppily it may look like an "i" -NEVER USE spell out every day or daily

answer

*q.d.

question

-every other day -mistaken as q.d. when the period after the "o" is mistaken for a period -NEVER USE spell out every other day

answer

*q.o.d

question

-subcutaneous -mistaken for SL (sublingual) or 5Q ("5 every") -spell out subcut or subcutaneous

answer

*SC, SQ, sub-Q

question

-one half -mistaken for 55 -use one half or 1/2

answer

*ss with line over

question

-less than, greater than -mistaken for each other -spell out less than, greater than

answer

*

question

-coronary (cardiac) care unit

answer

CCU

question

-emergency care unit

answer

ECU

question

-emergency room

answer

ER

question

-intensive care unit

answer

ICU

question

-impatient (a patient who is admitted to the hospital for care and assigned a bed)

answer

IP

question

-outpatient (a patient who is treated in an ambulatory facility in an office, clinic, or hospital who goes home after treatment and is not admitted to the hospital for an overnight stay)

answer

OP

question

-operating room

answer

OR

question

-post anesthesia care unit

answer

PACU

question

-post anesthesia recovery

answer

PAR

question

-post operative

answer

post-op

question

-pre operative

answer

pre-op

question

-return to clinic

answer

RTC

question

-return to office

answer

RTO

question

-bathroom privileges

answer

BRP

question

-chest pain

answer

CP

question

-ethyl alcohol

answer

ETOH

question

-left

answer

(L) with circle around

question

-right

answer

(R) with circle around

question

-murmur

answer

(m) with circle around

question

-patient

answer

Pt

question

-regular rate and rhythm

answer

RRR

question

-shortness of breath

answer

SOB

question

-treatment

answer

Tr

question

-treatment; traction

answer

Tx

question

-vital signs (temperature, pulse, respiration, and blood pressure)

answer

VS

question

-temperature

answer

T

question

-pulse

answer

P

question

-respiration

answer

R

question

-blood pressure

answer

BP

question

-height

answer

Ht

question

-weight

answer

Wt

question

-well developed and well nourished

answer

WDWN

question

-year old

answer

y/o or y.o.

question

-number or pound

answer

#

question

-celsius, centigrade

answer

C

question

-fahrenheit

answer

F

question

-evaluate medical records and documentation concerning patient diagnoses and services rendered in order to accurately and completely bill for those services

answer

medical billers/coders

question

-procedural codes

answer

CPT code

question

-the diagnostic codes

answer

ICD-9-CM

question

-centimeter -2.5cm=1in

answer

cm

question

-gram

answer

g or gm

question

-kilogram -equals 2.2 lbs

answer

kg

question

-liter

answer

L

question

-milligram

answer

mg

question

-milliliter

answer

mL

question

-millimeter

answer

mm

question

-cubic millimeter

answer

cu mm or mm^3

question

-fluid ounce

answer

fl oz

question

-grain

answer

gr

question

-drop -Latin gutta=drop

answer

gt

question

-drops

answer

gtt

question

-method of liquid and weight measures that was used by the earliest chemists and pharmacist -based on the drop for liquid and the one grain of wheat for weight -the small apothecary measures are rarely used, but larger ones like fluid ounce is still common

answer

apothecary system

question

-ounce

answer

oz

question

-pound -equal to 16 ounces

answer

lb or #

question

-quart -equal to 32 ounces

answer

qt

question

-tablet

answer

tab

question

-capsule

answer

cap

question

-in the cheek

answer

buccal

question

-oral -by mouth

answer

p.o.

question

-sublingual -under the tongue

answer

SL

question

-suppository

answer

suppos

question

-vaginal -per vagina

answer

PV

question

-rectal -per rectum

answer

PR

question

-inhaled through the nose or mouth

answer

inhalation

question

-spray

answer

aerosol

question

-device used to produce a fine spray or mist, often in a metered dose

answer

nebulizer

question

-by injection

answer

pareternal

question

-intradermal -within the skin

answer

ID

question

-intramuscular -within the muscle

answer

IM

question

-intravenous -within the vein

answer

IV

question

-subcutaneous -under the skin -write out "sub cut" or "subcutaneous"

answer

*SC, SQ, sub-q

question

-applied to the surface of the skin -examples: cream, lotion, ointment

answer

topical

question

-absorption of drug through unbroken skin

answer

transdermal

question

-a drug reservoir imbedded in the body to provide continual infusion of a medication -example: insulin pump

answer

implant

question

-recipe -prescription -an order to supply a patient with a particular drug of a specific strength and quantity along with the Sig: (specific instructions for administration)

answer

Rx

question

-assigned to a drug in the laboratory at the time it is invented -the formula for the drug, which is written exactly according to its chemical structure

answer

chemical name

question

-the official, nonproprietary name given

answer

generic name

question

-is the manufacturer's name for a drug

answer

trade or brand name

question

-over the counter drugs -do not require a prescription -example: aspirin/acetylsalicylic acid/ASA (brand name Bufferin, Ascriptin) -ibuprofen (brand name Motrin, Advil)

answer

OTC

question

-assits pharmacists in providing medications and services to meet the needs of patients -accepting and evaluating prescriptions, entering information in the computerized patient profile, retrieving medication and placing it in the labeled container, filling unit dose medication carts and delivering, stocking and maintaining automated medication dispensers, using aseptic technique to mix IV medications

answer

pharmacy technician

question

-before -ante

answer

a (with line over)

question

-before meals -ante cibum

answer

a.c.

question

-before noon -ante meridiem

answer

a.m.

question

-twice a day -bis in die

answer

b.i.d.

question

-day

answer

d

question

-hour -hora

answer

h

question

-at the hour of sleep (bedtime) -hora somni -spell out bedtime

answer

*h.s.

question

-night -noctis

answer

noc

question

-after -post

answer

p with line over

question

-after meals -post cibum

answer

p.c.

question

-after noon -post meridiem

answer

p.m.

question

-as needed -pro re nata

answer

p.r.n.

question

-every -quaque

answer

q

question

-every day -quaque die -NEVER USE, spell out every day or daily

answer

*q.d.

question

-every hour -quaque hora

answer

qh

question

-every two hours

answer

q2h

question

-four times a day -quarter in die

answer

q.i.d.

question

-every other day -quaque altera die -NEVER USE, spell out every other day

answer

*q.o.d.

question

-immediately -statium

answer

STAT

question

-three times a day -ter in die

answer

t.i.d.

question

-week

answer

wk

question

-year

answer

yr

question

-as desired -ad libitum

answer

ad lib.

question

-right ear -auris dextra -spell out right ear

answer

*AD

question

-left ear -auris sinistra -spell out left ear

answer

*AS

question

-both ears -auris unitas -spell out both ears

answer

*AU

question

-with -cum

answer

c with line over

question

-nothing by mouth -non per os

answer

NPO

question

-right eye -oculus dexter -spell out right eye

answer

*OD

question

-left eye -oculus sinister -spell out left eye

answer

*OS

question

-both eyes -oculi unitas -spell out both eyes

answer

*OU

question

-by or through

answer

per

question

-by mouth -per os

answer

p.o.

question

-without -sine

answer

s with line over

question

-label; instruction to the patient -signa

answer

Sig

question

-one half -semis -spell out one half or use 1/2

answer

*ss with line over

question

-times of for -x6 = six times -x2d = for two days

answer

x

question

-electronic health records -improved documentation -medication management -assistance with clinical decision making -interoperability

answer

EHR

question

-drawing a single line through the error -then write the correction -include date and initials of person making correction -correction fluid is forbidden!

answer

corrections

question

-always include the month, day, and year

answer

date

question

-military time

answer

time

question

-historically prescriptions were written in Latin -often abbreviated with periods indicating separate words -now we use uppercase letters instead of lowercase, periods are being discouraged because in handwritten notes they can be mistaken

answer

latin

question

-used exclusively in the early days -still being used today, but most pharmacy organizations now promote the use of Arabic numerals only

answer

roman numerals

question

-before in latin

answer

ante

question

-meals in latin

answer

cibum

question

-noon in latin

answer

meridiem

question

-twice in latin

answer

bis

question

-day in latin

answer

dis/die

question

-hour in latin

answer

hora

question

-sleep in latin

answer

somni

question

-night in latin

answer

notis

question

-after in latin

answer

post

question

-as needed in latin

answer

pro re nata

question

-every in latin

answer

quaque

question

-four in latin

answer

quarter

question

-every other day in latin

answer

quaque altera die

question

-immediately in latin

answer

statium

question

-three times a day in latin

answer

ter in die

question

-without in latin

answer

sine

question

-label in latin

answer

signa

question

-one half in latin

answer

semis

question

-ear in latin

answer

auris

question

-left in latin

answer

dextra/dexter

question

-left in latin

answer

sinistra

question

-both in latin

answer

unitas

question

-eye in latin

answer

oculus

question

-as desired in latin

answer

ad libitum

question

-with in latin

answer

cum

question

-nothing in latin

answer

non

question

-by mouth in latin

answer

per os

question

-drop in latin

answer

gutta

question

-prefix means without

answer

afrebrile

Medical Terminology Chapter 3 Health Care Records – Flashcards

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