Common Charting Terms and Medical Abbreviations Flashcards
Objective
Physical observations
Subjective
Anything about the patient
Assessment
Diagnosis
Plan
Treatment
acute
Severe symptoms, over a short time
benign
Mild; noncancerous tumor
chronic
Develops slowly over time
degeneration
Gradual deterioration of the body function over time
diagnosis
A physicians determination of the disease based on findings
etiology
Cause of the disease
exacerbation
Increase in severity
febrile
Having an elevated temperature
gross
Visible to the naked eye
idiopathic
No clear cause
localized
Confined to one area
malignant
Harmful, cancerous tumor
marked
Important, note-worthy
morbidity
State or presence of disease
mortality
Death
prognosis
Prediction of outcome
progressive
Continuing severity
prophylaxis
Measures that prevent
recurrent
Happening repeatedly
systemic
Throughout the body
unremarkable
Unimportant
inhalation
Vapor or gas inhaled that has entered the blood stream
oral
Drug taken by mouth to get to the blood stream
rectal
Drug in form of liquid that is inserted into the blood stream
sublingual
Drug placed under the tounge to dissolve in the mouth
topical
Drugs applied to a certain area
transdermal
patch: drug that is absorbed through the skin
parenteral
"Injected: Intradermal: within the skin Intramuscular: within the muscle Itravenous: into the vein Subcutaneous: just under the skin"
A
Assesment/ Analysis
ADL
Activities of daily living
BP
Blood pressure
CC
Chief complaint
c/o
Complaint of
CP
Chest pain