Chapter 1: Medical Records & Acronyms/Abbreviations Flashcards
Abdominal adhesion
Usually involves the intestines and is caused by inflammation or trauma. This of adhesion may cause an intestinal obstruction and require surgery
Afferent
Carry impulses towards a center
Efferent
Carrying impulses away from a center
Febrile
Pertaining to fever, a sustained body temperature (T) above 98.6F
Benign tumor
Non-cancerous
Malignant tumor
Cancerous
Rapport
Relationship of understanding between two individuals, especially between the patient and the physician
Sign
Clinical evidence of an illness or disordered function of the body; can be seen, heard, measured or felt by the examiner
Syndrome
A group of signs and symptoms occurring together that characterize a specific disease pathological condition
Electronic Health record (ehr)
Electronic record of health– Related information by clinicians and staff
Patient Data
Information that is provided by the patient; DOB, marital status, Street address, city, state, zipcode, phone number, insurance information, employment, etc.
Medical history (Hx)
Document describing past and current history of all medical conditions experienced by the patient
Physical examination (PE)
Head-to-toe assessment of the patients physical conditions
Consent Form
Signed document by the patient or legal guardian giving permission for treatment
Informed consent form
Signed document by the patient or legal guardian that explains the purpose, risks, and benefits of a procedure and serves as proof that the patient was properly informed before undergoing a procedure
Physician’s orders
Record of the prescribed care, medications, tests, and treatments for a given patient
Nurse’s notes
Record of a patients care that includes vital signs, particularly temperature(T), pulse (P), respiration (R), and blood pressure (BP), along with treatments, procedures,and patients response tocare
Physicians progress notes
Documentation given by the physician regarding the patients condition, results of the physicians examination, summary of test results, plan of treatment, and updating data
Consultation reports
Documentation given by specialists whom the physician has asked to evaluate the patient
Ancillary/miscellaneous reports
Documentation of procedures or therapies
Diagnostic tests/laboratory reports
Documents providing the results of diagnostic and laboratory tests performed on a patient
Operative report
Documentation from a surgeon detailing pre-op, post-op, details of the surgical procedure, how the patient did during the procedure, and any complications that occurred
Anesthesiology report
Documentation from the attending anesthesiologist or nurse anesthetist that includes a detailed account of anesthesia during surgery, which drugs were used, dose and time given, patient response, monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that occurred
Pathology report
Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue
Discharge report
Information given to the patient regarding date of admission, diagnosis, treatment, test results, follow up plan, and date of discharge
Soap: chart note
Subjective, objective, assessment, plan
Ad
Alzheimer’s disease
AIDET
Acknowledge, introduce, duration, explanation, thank you
Ax
axillary
BP
Blood pressure
Bx
Biopsy
C
Centigrade, Celsius
CA
Cancer
CC
Chief complaint
CDC
Centers for disease control and prevention
cm
Centimeter
CUA
Cerebrovascular accident
DM
Diabetes mellitus
DOB
Date of birth
Dx
Diagnosis
HIPAA
Health insurance portability and accountability act
Ht
Height
Hx
Medical history
P
Pulse
Path
Pathology
R
Respiration
SBAR
Situation, background, assessment, recommendation
T
Temperature
TJC
The joint commission
Tor
Temperature, pulse, respiration
Wt
Weight
