Medical Terminology Chapter 3 Health Care Records

A
-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
A&W; L&W
-alive and well; living and well
CC
-chief complaint
-reason for seeking medical care
c/o
-complains of
Dx
-diagnosis
-identification of a disease or condition is recorded here
FH
-family history
-state of health of immediate family members (father, mother, and siblings)
HEENT
-head, eyes, ears, nose, and throat
H&P
-history and physical
HPI; PI
-history of present illness; present illness
-details of the complaint noting duration and severity
Hx
-history
IMP
-impression
-identification of a disease or condition is recorded here
NAD
-no acute distress
NKDA
-no known drug allergies
O
-objective information
-observable information (ex: test results, blood pressure readings, etc.)
OH
-occupational history
-work habits that may involve health risks
P
-plan (also recommendation, disposition)
-decision to proceed or to alter the plan strategy
PE; Px
-physical examination
PERRLA
-pupils equal, round, and reactive to light accommodation
PH; PMH
-past history; past medical history
R/O
-rule out
ROS; SR
-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
S
-subjective information
-that which the patient describes
SH
-social history
-patient’s recreational interests
Sx
-symptom
-subjective evidence of illness
UCHD
-usual childhood diseases
WNL
-within normal limits
SOAP method
-subjective, objective, assessment, plan
differential diagnosis
-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
signs
-objective evidence of disease including swelling, skin color changes, visible response to pain, deformation, and abnormal vital signs, etc.
preoperative H&P
-a current H&P report before admitting a patient to the hospital for surgery
radiologic technologists
-also referred to as radiographers
hypertension
-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
history and physical
-often the first document entered into the patient’s hospital record
physician’s orders
-list the directives for care prescribed by the doctor attending to the patient
nurse’s & physician’s progress notes
-chronicle the care throughout the patient’s stay
consultation report
-filed after a specialist examines the patient
operative report
-narrative report after surgery filed by the primary surgeon
anesthesiologist’s report
-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
informed consent
-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
ancillary reports
-note any additional procedures and therapies, including diagnostic test and pathology reports
discharge summary (clinical resume, clinical summary, discharge abstract)
-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
ENT
-ear nose and throat specialist
JCAHO
-joint commission of accreditation of healthcare organizations
*AD, AS, AU
-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
*OD, OS, OU
-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
*cc
-cubic centimeter
-mistaken as units
-use the metric equivalent mL
*DC, D/C
-discharge, discontinue
-mistaken for “discontinue” when followed by medications prescribed at the time of discharge
-spell out discharge, discharge
*h.s.
-bedtime
-mistaken as “half strength”
-spell out bedtime
*q.d.
-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
*q.o.d
-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
*SC, SQ, sub-Q
-subcutaneous
-mistaken for SL (sublingual) or 5Q (“5 every”)
-spell out subcut or subcutaneous
*ss with line over
-one half
-mistaken for 55
-use one half or 1/2
*<,>
-less than, greater than
-mistaken for each other
-spell out less than, greater than
CCU
-coronary (cardiac) care unit
ECU
-emergency care unit
ER
-emergency room
ICU
-intensive care unit
IP
-impatient (a patient who is admitted to the hospital for care and assigned a bed)
OP
-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)
OR
-operating room
PACU
-post anesthesia care unit
PAR
-post anesthesia recovery
post-op
-post operative
pre-op
-pre operative
RTC
-return to clinic
RTO
-return to office
BRP
-bathroom privileges
CP
-chest pain
ETOH
-ethyl alcohol
(L) with circle around
-left
(R) with circle around
-right
(m) with circle around
-murmur
Pt
-patient
RRR
-regular rate and rhythm
SOB
-shortness of breath
Tr
-treatment
Tx
-treatment; traction
VS
-vital signs (temperature, pulse, respiration, and blood pressure)
T
-temperature
P
-pulse
R
-respiration
BP
-blood pressure
Ht
-height
Wt
-weight
WDWN
-well developed and well nourished
y/o or y.o.
-year old
#
-number or pound
C
-celsius, centigrade
F
-fahrenheit
medical billers/coders
-evaluate medical records and documentation concerning patient diagnoses and services rendered in order to accurately and completely bill for those services
CPT code
-procedural codes
ICD-9-CM
-the diagnostic codes
cm
-centimeter
-2.5cm=1in
g or gm
-gram
kg
-kilogram
-equals 2.2 lbs
L
-liter
mg
-milligram
mL
-milliliter
mm
-millimeter
cu mm or mm^3
-cubic millimeter
fl oz
-fluid ounce
gr
-grain
gt
-drop
-Latin gutta=drop
gtt
-drops
apothecary system
-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
oz
-ounce
lb or #
-pound
-equal to 16 ounces
qt
-quart
-equal to 32 ounces
tab
-tablet
cap
-capsule
buccal
-in the cheek
p.o.
-oral
-by mouth
SL
-sublingual
-under the tongue
suppos
-suppository
PV
-vaginal
-per vagina
PR
-rectal
-per rectum
inhalation
-inhaled through the nose or mouth
aerosol
-spray
nebulizer
-device used to produce a fine spray or mist, often in a metered dose
pareternal
-by injection
ID
-intradermal
-within the skin
IM
-intramuscular
-within the muscle
IV
-intravenous
-within the vein
*SC, SQ, sub-q
-subcutaneous
-under the skin
-write out “sub cut” or “subcutaneous”
topical
-applied to the surface of the skin
-examples: cream, lotion, ointment
transdermal
-absorption of drug through unbroken skin
implant
-a drug reservoir imbedded in the body to provide continual infusion of a medication
-example: insulin pump
Rx
-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)
chemical name
-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
generic name
-the official, nonproprietary name given
trade or brand name
-is the manufacturer’s name for a drug
OTC
-over the counter drugs
-do not require a prescription
-example: aspirin/acetylsalicylic acid/ASA (brand name Bufferin, Ascriptin)
-ibuprofen (brand name Motrin, Advil)
pharmacy technician
-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
a (with line over)
-before
-ante
a.c.
-before meals
-ante cibum
a.m.
-before noon
-ante meridiem
b.i.d.
-twice a day
-bis in die
d
-day
h
-hour
-hora
*h.s.
-at the hour of sleep (bedtime)
-hora somni
-spell out bedtime
noc
-night
-noctis
p with line over
-after
-post
p.c.
-after meals
-post cibum
p.m.
-after noon
-post meridiem
p.r.n.
-as needed
-pro re nata
q
-every
-quaque
*q.d.
-every day
-quaque die
-NEVER USE, spell out every day or daily
qh
-every hour
-quaque hora
q2h
-every two hours
q.i.d.
-four times a day
-quarter in die
*q.o.d.
-every other day
-quaque altera die
-NEVER USE, spell out every other day
STAT
-immediately
-statium
t.i.d.
-three times a day
-ter in die
wk
-week
yr
-year
ad lib.
-as desired
-ad libitum
*AD
-right ear
-auris dextra
-spell out right ear
*AS
-left ear
-auris sinistra
-spell out left ear
*AU
-both ears
-auris unitas
-spell out both ears
c with line over
-with
-cum
NPO
-nothing by mouth
-non per os
*OD
-right eye
-oculus dexter
-spell out right eye
*OS
-left eye
-oculus sinister
-spell out left eye
*OU
-both eyes
-oculi unitas
-spell out both eyes
per
-by or through
p.o.
-by mouth
-per os
s with line over
-without
-sine
Sig
-label; instruction to the patient
-signa
*ss with line over
-one half
-semis
-spell out one half or use 1/2
x
-times of for
-x6 = six times
-x2d = for two days
EHR
-electronic health records
-improved documentation
-medication management
-assistance with clinical decision making
-interoperability
corrections
-drawing a single line through the error
-then write the correction
-include date and initials of person making correction
-correction fluid is forbidden!
date
-always include the month, day, and year
time
-military time
latin
-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
roman numerals
-used exclusively in the early days
-still being used today, but most pharmacy organizations now promote the use of Arabic numerals only
ante
-before in latin
cibum
-meals in latin
meridiem
-noon in latin
bis
-twice in latin
dis/die
-day in latin
hora
-hour in latin
somni
-sleep in latin
notis
-night in latin
post
-after in latin
pro re nata
-as needed in latin
quaque
-every in latin
quarter
-four in latin
quaque altera die
-every other day in latin
statium
-immediately in latin
ter in die
-three times a day in latin
sine
-without in latin
signa
-label in latin
semis
-one half in latin
auris
-ear in latin
dextra/dexter
-left in latin
sinistra
-left in latin
unitas
-both in latin
oculus
-eye in latin
ad libitum
-as desired in latin
cum
-with in latin
non
-nothing in latin
per os
-by mouth in latin
gutta
-drop in latin
afrebrile
-prefix means without