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Scribe terminology > Abbreviations > Flashcards

Abbreviations Flashcards

1
Q

Abd

A

Abdominal

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2
Q

Abx

A

Antibiotics

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3
Q

A fib

A

Atrial fibrillation

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4
Q

AOM

A

Acute Otitis Media (new ear infection)

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5
Q

A/P

A

Assessment and plan

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6
Q

ASA

A

Acetylsalicylic acid (aspirin)

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7
Q

BID

A

Twice daily

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8
Q

Bilat LE

A

Bilateral lower extremities

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9
Q

C (with line)

A

With

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10
Q

CA

A

Cancer, carcinoma

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11
Q

CABG

A

Coronary artery bypass graft

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12
Q

CAD

A

Coronary artery disease

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13
Q

CBC

A

Complete blood count (blood work for infection or anemia )

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14
Q

CHF

A

Congestive heart failure

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15
Q

CP

A

Chest pain

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16
Q

C/o

A

Complains of

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17
Q

COPD

A

Coronary obstructive pulmonary disease

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18
Q

CRF

A

Chronic renal failure

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19
Q

C-spine

A

Cervical spine

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20
Q

CT or CAT

A

Computerized assisted tomography

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21
Q

CTA

A

Clear to ascultation

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22
Q

CV

A

Cardiovascular

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23
Q

CVA

A

Cerebrovascular accident

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24
Q

CXR

A

Chest X ray

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25
Q

DM

A

Diabetes mellitus

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26
Q

DOE

A

Dyspnea on exertion

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27
Q

DP/ PT (pulse)

A

Dorsalis pedis / posterior tibialis

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28
Q

DVT

A

Deep vein thrombosis

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29
Q

Dx

A

Diagnosis

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30
Q

EKG/ ECG

A

Electrocardiogram

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31
Q

EOMI

A

Extraocular movements intact

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32
Q

EtOH

A

Alcohol

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33
Q

FHx

A

Family history

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34
Q

F/U

A

Follow up

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35
Q

Fx

A

Fracture

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36
Q

GERD

A

Gastroesophageal reflux

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37
Q

GI

A

Gastrointestinal

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38
Q

G/P/ ab

A

Gravida, para, abortion

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39
Q

GU

A

Genitourinary

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40
Q

HA

A

Headache

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41
Q

HEENT

A

Head ears eyes nose throat

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42
Q

HIPAA

A

Health insurance portability and accountability act

43
Q

HLD

A

Hyperlipidemia

44
Q

HPI

A

History of present illness

45
Q

HTN

A

Hypertension

46
Q

Hx

A

History

47
Q

H&h

A

Hemoglobin and hematocrit

48
Q

I&d

A

Incision and drainage

49
Q

IDDM

A

Insulin dependent diabetes mellitus

50
Q

IUP

A

Intrauterine pregnancy

51
Q

IVDA

A

Intravenous drug abuse

52
Q

LLE

A

Left lower extremity

53
Q

LLQ

A

Left lower quadrant

54
Q

LNMP

A

Last normal menstrual period

55
Q

LOC

A

Loss of consciousness

56
Q

l-spine

A

Lumbar spine

57
Q

LUE

A

Left upper extremity

58
Q

LUQ

A

Left upper quadrant

59
Q

NAD

A

Not acute distress

60
Q

NIDDM

A

Non insulin dependent diabetes mellitus

61
Q

NKDA

A

No known drug allergies

62
Q

Nl/ nml

A

Normal

63
Q

NSR

A

Normal sinus rhythm

64
Q

n/ v/ d

A

Nausea, vomiting, diarrhea

65
Q

OM

A

Otitis media (inner ear infection)

66
Q

OP

A

Oropharynx (mouth and throat )

67
Q

ORIF

A

Open reduction and internal fixation (orthopedic surgery )

68
Q

PCP/ PMID

A

Primary care physician, primary medical doctor

69
Q

PE

A

Physical exam / pulmonary embolism

70
Q

PERRL

A

Pupils are equal, round, reactive to light

71
Q

PO

A

Per os (by mouth)

72
Q

Prn

A

As needed

73
Q

Pt

A

Patient

74
Q

PTA

A

Prior to arrival / peritonsillar abscess

75
Q

PVD

A

Peripheral vascular disease

76
Q

Q

A

Every

77
Q

QD

A

Every day

78
Q

QHS

A

Every bedtime

79
Q

QID

A

4x a day

80
Q

RLE

A

Right lower extremity

81
Q

RLQ

A

Right lower quadrant

82
Q

ROM

A

Range of motion

83
Q

ROS

A

Review of system

84
Q

RRR

A

Regular rate and rhythm (heart sounds)

85
Q

RUE

A

Right upper extremity

86
Q

RUQ

A

Right upper quadrant

87
Q

R/o

A

Rule out

88
Q

SOB

A

Shortness of breath

89
Q

SOAP

A

Subjective, objective, assessment, and plan

90
Q

S/p

A

Status post (after)

91
Q

Sx

A

Symptoms

92
Q

STEMI

A

S/T elevation myocardial infarction

93
Q

T&A

A

Tonsillectomy and adenoidectomy

94
Q

TIA

A

Transient ischemic attack

95
Q

TID

A

Three X daily

96
Q

TM

A

Tympanic membrane (ear drum)

97
Q

T-spine

A

Thoracic spine

98
Q

UA

A

Urinalysis

99
Q

URI

A

Upper respiratory infection

100
Q

US

A

Ultrasound

101
Q

UTD

A

Up to date

102
Q

UTI

A

Urinary tract infection

103
Q

WNL

A

Within normal limits

104
Q

Y/o

A

Years old

Scribe terminology (2 decks)

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