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Medical Terminology > Chapter 1: Medical Records & Acronyms/Abbreviations > Flashcards

Chapter 1: Medical Records & Acronyms/Abbreviations Flashcards

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USMLE® Step 1 flashcards
1
Q

Abdominal adhesion

A

Usually involves the intestines and is caused by inflammation or trauma. This of adhesion may cause an intestinal obstruction and require surgery

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2
Q

Afferent

A

Carry impulses towards a center

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3
Q

Efferent

A

Carrying impulses away from a center

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4
Q

Febrile

A

Pertaining to fever, a sustained body temperature (T) above 98.6F

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5
Q

Benign tumor

A

Non-cancerous

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6
Q

Malignant tumor

A

Cancerous

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7
Q

Rapport

A

Relationship of understanding between two individuals, especially between the patient and the physician

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8
Q

Sign

A

Clinical evidence of an illness or disordered function of the body; can be seen, heard, measured or felt by the examiner

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9
Q

Syndrome

A

A group of signs and symptoms occurring together that characterize a specific disease pathological condition

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10
Q

Electronic Health record (ehr)

A

Electronic record of health– Related information by clinicians and staff

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11
Q

Patient Data

A

Information that is provided by the patient; DOB, marital status, Street address, city, state, zipcode, phone number, insurance information, employment, etc.

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12
Q

Medical history (Hx)

A

Document describing past and current history of all medical conditions experienced by the patient

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13
Q

Physical examination (PE)

A

Head-to-toe assessment of the patients physical conditions

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14
Q

Consent Form

A

Signed document by the patient or legal guardian giving permission for treatment

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15
Q

Informed consent form

A

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

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16
Q

Physician’s orders

A

Record of the prescribed care, medications, tests, and treatments for a given patient

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17
Q

Nurse’s notes

A

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

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18
Q

Physicians progress notes

A

Documentation given by the physician regarding the patients condition, results of the physicians examination, summary of test results, plan of treatment, and updating data

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19
Q

Consultation reports

A

Documentation given by specialists whom the physician has asked to evaluate the patient

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20
Q

Ancillary/miscellaneous reports

A

Documentation of procedures or therapies

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21
Q

Diagnostic tests/laboratory reports

A

Documents providing the results of diagnostic and laboratory tests performed on a patient

22
Q

Operative report

A

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

23
Q

Anesthesiology report

A

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

24
Q

Pathology report

A

Documentation from the pathologist regarding the findings or results of samples taken from the patient, such as bone marrow, blood, or tissue

25
Q

Discharge report

A

Information given to the patient regarding date of admission, diagnosis, treatment, test results, follow up plan, and date of discharge

26
Q

Soap: chart note

A

Subjective, objective, assessment, plan

27
Q

Ad

A

Alzheimer’s disease

28
Q

AIDET

A

Acknowledge, introduce, duration, explanation, thank you

29
Q

Ax

A

axillary

30
Q

BP

A

Blood pressure

31
Q

Bx

A

Biopsy

32
Q

C

A

Centigrade, Celsius

33
Q

CA

A

Cancer

34
Q

CC

A

Chief complaint

35
Q

CDC

A

Centers for disease control and prevention

36
Q

cm

A

Centimeter

37
Q

CUA

A

Cerebrovascular accident

38
Q

DM

A

Diabetes mellitus

39
Q

DOB

A

Date of birth

40
Q

Dx

A

Diagnosis

41
Q

HIPAA

A

Health insurance portability and accountability act

42
Q

Ht

A

Height

43
Q

Hx

A

Medical history

44
Q

P

A

Pulse

45
Q

Path

A

Pathology

46
Q

R

A

Respiration

47
Q

SBAR

A

Situation, background, assessment, recommendation

48
Q

T

A

Temperature

49
Q

TJC

A

The joint commission

50
Q

Tor

A

Temperature, pulse, respiration

51
Q

Wt

A

Weight

Medical Terminology (7 decks)

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