BN3 Flashcards
Assessment
-Diagnosis based on the data gathered from the subjective and objective of the patient
Objective
-Data which is measured and observed from the patient
Pertinent
-Relevant
Plan
-Care and treatment that the provider will be using to resolve the patients problem
Subjective
-Data obtained from verbalization’s from the patient
abd
-Abdominal
ABG
-Arterial blood gas
a.c.
-Before meals
ACLS
-Advanced cardiac life support
ADL
-Activities of daily living
ad lib
-As desired
am
-Morning
AMA
-Against medical advice
AMI
-Acute myocardial infarction (heart attack)
Amp
-Ampoule
amt
-Amount
A&Ox3
-Alert and oriented to person, place and time
ASA
-Acetylsalicylic acid or asprin
ASAP
-As soon as possible
bid
-Twice a day
bil, bilateral
-Both sides
BLS
-Basic life support
BM
-Bowel movement
B/P
-Blood pressure
BS
-Breath sounds or bowel souds
BSI
-Body substance isolation
BVM
-Bag valve mask
/c
-With
cap(s)
-Capsule(s)
c-spine
-Cervical spine
CBC
-Complete blood count
C/C
-Chief complaint
CHF
-Congestive heart failure
CNS
-Central Nervous system
c/o
-Complains of
COPD
-Chronic obstructive pulmonary disease
CPR
-Cardiopulmonary resuscitation
CSF
-Cerebrospinal fluid
CVA
-Cerebrovascualr accident (stroke)
CXR
-Chest X-Ray
Daily
-Once a day
DC
-Discontinue
dil.
-Dilute
DNR
-Do not resusitate
DOA
-Dead on arrival
DOB
-Date of birth
D5W
-5% dextrose in water
DX
-Diagnosis
ECG or EKG
-Electrocardiogram
ET
-Endotracheal
ETA
-Estimated time of arrival
ETOH
-Ethyl alcohol
Elix.
-Elixer
FBOA
-Foreign body obstructed airway
fl, fld
-Fluid
FX
-Fracture
g
-Gram
GI
-Gastrointestinal
gr
-Grain
gtt, gtts
-Drop, drops
h, hr
-Hour
HEENT
Head, eyes, ears, nose, throat
HDL
-High density lipoprotein
HIV
-Human immunodeficiency virus
HR
-Heart rate
HRR
-Heart rate regular
hs
-Hour of sleep, bedtime
ht
-Height
HTN
-Hypertension
HX
-History
I&D
-Incision and drainage
ID
-Intradermal
IM
-Intramuscular
INH
-Isoniazid (a drug prescribed for the treatment and prevention of tuberculosis)
inj.
-By injection
Irrig.
-Irrigation
IV
-Intravenous
IVP
-IV push
IVPB
-IV piggyback
kg
-Kilogram
kvo
-Keep vein open
L
-liter
lb, lbs
-Pound, pounds
LDL
-low density lipoprotien
LCTAB
-Lungs clear to auscultation bilaterally
LLQ, LLL
-Left Left lower quadrant (abdomen), left upper lobe (lung)
LMP
-Last menstrual period
LOC
-Level of consciousness or loss of consciousness
LOI
-Last oral intake
LP
-Lumbar puncture (Spinal tap)
LR
-Lactated ringer
LUQ, LUL
-Left upper quadrant (abdomen), Left upper lobe (lung)
meg
-Microgram
mg
-Milligram
mL
-Millimeter
MVA
-Motor vehicle accident
NIDDM
-noninsulin-dependent diabetes mellitus
NVD
-Nausea, vomiting, diarreah
neg
-Negetive
NKA, NKDA
-No known allergies, no known drug allergies
NPO
-Nothing by mouth
NS, NaCI
-Normal saline
NSR
-Normal sinus rhythm
oz
-Ounce
p
-After
p.c.
-After meals
PCN
-Penicillin
per
-by or through
PERRLA
-Pupils equal, round, reactive to light, and accomodation
pm
-Between noon and midnight
PO
-By mouth
prn
-As needed, whenever necessary
PT
-Patient or physical therapy
PE
-Physical exam
q
-Every
qh
-Every hour
q2h
-Every 2 hours, any number can be used
qhs
-Every night at bedtime
qid
-Four times a day
qt
-Quart
R, PR
-Rectal, per rectum
RLQ, RLL
-Right lower quadrant (abdomen) right lower lobe (lung)
RML
-Right middle lobe
R/O
-Rule out
ROM
-Range of motion
RUQ, RUL
-Right upper quadrant (abdomen), Right upper lobe (lung)
Rx
-Prescription
/s
-Without
S.L.
Sublingual
SOB
-Shortness of breath
subQ, Sub-Q
-Subcutaneous
Stat
-Immediately
SX
-Symptoms
tab
-Tablet
Tbsp
-Tablespoon
tsp
-Teaspoon
tid
-Three times a day
Tx
-Treatment
UA
-Urinalysis
URI
-Upper respiratory infection
V/S
-Vital signs
VSS
-Vital signs stable
WBC
-White blood cell
WNL
-Within normal limits
wt
-Weight
Chronological
-Arranged according to the order of time
Dental record
-A file of continuous dental care and treatment given to active duty, reserve members and their families
Family Member Prefix (FMP)
-A number that designates sponsor ship
Health record (HREC)
-A file of continuous care given to an active duty member and documents all outpatient care provided during a members career.
Inpatient Record (IREC)
-A medical file which documents care provided to a patient assigned to a designated inpatient bed in a medical treatment facility
Outpatient record (OREC)
-A file of continuous care which documents ambulatory treatment received by a person other than an active duty member (Retirees and family members)
Military Treatment Facility (MTF)
-Location of military health records
2100 Jacket
-Orange 0 series
2110 Jacket
-Green 1 series
2120 Jacket
-Yellow 2 series
2130 Jacket
-Gray 3 series
2140 Jacket
-Mustard/Tan 4 series
2150 Jacket
-Blue 5 series
2160 Jacket
-White 6 series
2170 Jacket
-Brown 7 series
2180 Jacket
-Pink 8 series
2190 Jacket
-Red 9 series
20 in family prefix
-Sponsor
30 in family prefix
-Spouse
31 in family prefix
-Second spouse
01 in family prefix
-First child
02 in family prefix
-Second child
99 in family prefix
-Foreign military
Part 1 in health record division
-Record of preventive medicine and occupational health
Part 2 in health record division
-Chronological record of medical care and treatment
Part 3 in health record division
-Physical qualifications physical profiles and exposure form
Part 4 in health record division
-Record of ancillary studies and misc. forms.
(Part 1) SF 601 or DD form 2766C
-Immunization record concerning hypersensitivities and allergies
(Part 1) NAVMED 6000/2
-Chronological record of HIV testing
(Part 1) DD Form 2215
- Baseline audiogram.
- DD form 2216 may accompany if member is in hearing conservation program
(Part 1) DD From 2766
-Adult preventive and chronic care flowsheet
(Part 2) SF 600
-Chronological record of medical care
(Part 2) SF 558
- Emergency care and treatment
- Interfiled with SF 600’s in chronological order
(Part 2) SF 502
- Narrative summary
- Summary of treatment received during periods of hospitalization
(Part 2) SF 507
-Medical record continuation
(Part 2) SF 509
- Progress notes
- Doctors
(Part 2) SF 513
- Consultation sheet
- Used to refer a patient to a specialist for detailed exam and/or procedure
- Filed immediately above SF 600 or SF 558 containing the last entry prior to the date of the SF513
(Part 2) AF Form 348
-Line of duty determination
(Part 2) AF Form 565
-Record of inpatient treatment
(Part 2) AF Form 1480
- Summary of care (Original)
- Health Enrollment assessment review (Original)
(Part 3) NAVMED 6150/4
- Abstract of service and medical history
- Record of duty stations that is listed chronologically
- Provides an abstract (diagnostic summary only) of medical history for each admission to the sick list
(Part 3) DD Form 2005
- Privacy act statement health care record
- Used to inform patients of their privacy rights concerning their health record.
- Don’t have to sign but rencouraged
(Part 3) DD Form 2569
-Third party collection program
(Part 3) OPNAV 5211/9
- Record of disclosure
- Release of medical information as required by the privacy act of 1974
(Part 3) DD Form 877
- Request for medical/dental records or information
- Used to permanently transfer records to another facility
(Part 3) DD Form 2795
-Pre-Deployment health assessment
(Part 3) DD Form 2796
- Post-Deployment health assessment (PDHA)
- Must be completed within 30 days of returning
(Part 3) DD Form 2900
- Post-Deployment health reassessment (PDHRA)
- Required after 6 months of returning
(Part 3) SF 88 or DD Form 2808
- Report of medical examination
- Filled out upon entry and discharge or retirement of the military
- Filed in conjunction with SF 93 or DD 2807-1
(Part 3) SF 93 or Form 2807-1
- Report of medical history
- Record of history upon entry, discharge or when physical examination is required. -Filed in conjunction with SF 88 or DD 2808
(Part 3) AF Form 422
-Physical profile serial support
(Part 4) SF 545
- Laboratory report display
- Sheet may be yellow
(Part 4) SF 519
- Radiological consultation requests/reports
- Sheet may be green
(Part 4) SF 602
-Lab results
Part 1 in forms in a dental record
-Contains dental X-Rays
Part 2 in forms in a dental record
-Contains NAVMED 6600/3 (Dental health questionnaire)
Part 3 in forms in a dental record
- Contains EZ 603 (Dental Exam Form)
- Used for most dental exams
Part 4 in forms in a dental record
-Contains EZ603A Form, SF 509 (Doctors progress notes)
NAVMED 6550/14 in forms in the inpatient health record
- Patient data base
- Summary of patients health history to identify nursing care problems.
- Patient completes section 1 nurse completes section 2 reviews section 1
SF 502 in forms in the inpatient health record
- Narrative summary
- To be completed by a medical officer and the origional SF 502 is filed in out patient or military health record
- A copy of SF 502 is filed in the inpatient treatment record
SF 504 in forms in the inpatient health record
- History part 1
- Record a course of current hospitalization. Including signs and symptoms, duration of complaints and the circumstances of admission.
- To be completed by a medical officer
SF 505 in forms in the inpatient health record
- History part 2 & 3
- Records occupation, military history, lifetime injuries and illness, as well as drug sensitivities and allergies.
- To be completed by a medical officer
SF 506 in forms in the inpatient health record
- Physical exam
- Record of physical examinations including physical and mental characteristics.
- To be completed by a medical officer
SF 508 in forms in the inpatient health record
- Doctors orders
- Instructions written by physician directing the medical care and treatment of patient
- Only nurses can accept verbal orders from doctor.
- Some are carbon forms so meds can be sent to pharmacy
SF 509 in forms in the inpatient health record
- Progress notes
- Used to record response to treatment
- Other personnel may use this to record comments
SF 510 in forms in the inpatient health record
- Nursing notes
- Observations, patient progress, treatments, and some meds are recorded on this form by nurses and corpsman.
NAVMED 6550/12 in forms in the inpatient health record
- Patient profile/ Air Force inpatient flow chart
- Used to standardize treatment and provide a ready reference for care given to a patient.
- Not apart of permanent record.
SF 511 in forms in the inpatient health record
-Vital signs record
NAVMED 6550/8 in forms in the inpatient health record
- Medication administration record
- Transcribed form doctors orders
- SF 508 to this form
DD 792 in forms in the inpatient health record
-Twenty four hour intake and output worksheet