Common Charting Terms and Medical Abbreviations Flashcards

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0
Q

Objective

A

Physical observations

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1
Q

Subjective

A

Anything about the patient

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2
Q

Assessment

A

Diagnosis

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3
Q

Plan

A

Treatment

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4
Q

acute

A

Severe symptoms, over a short time

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5
Q

benign

A

Mild; noncancerous tumor

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6
Q

chronic

A

Develops slowly over time

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7
Q

degeneration

A

Gradual deterioration of the body function over time

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8
Q

diagnosis

A

A physicians determination of the disease based on findings

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9
Q

etiology

A

Cause of the disease

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10
Q

exacerbation

A

Increase in severity

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11
Q

febrile

A

Having an elevated temperature

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12
Q

gross

A

Visible to the naked eye

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13
Q

idiopathic

A

No clear cause

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14
Q

localized

A

Confined to one area

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15
Q

malignant

A

Harmful, cancerous tumor

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16
Q

marked

A

Important, note-worthy

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17
Q

morbidity

A

State or presence of disease

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18
Q

mortality

A

Death

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19
Q

prognosis

A

Prediction of outcome

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20
Q

progressive

A

Continuing severity

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21
Q

prophylaxis

A

Measures that prevent

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22
Q

recurrent

A

Happening repeatedly

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23
Q

systemic

A

Throughout the body

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24
Q

unremarkable

A

Unimportant

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25
Q

inhalation

A

Vapor or gas inhaled that has entered the blood stream

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26
Q

oral

A

Drug taken by mouth to get to the blood stream

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27
Q

rectal

A

Drug in form of liquid that is inserted into the blood stream

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28
Q

sublingual

A

Drug placed under the tounge to dissolve in the mouth

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29
Q

topical

A

Drugs applied to a certain area

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30
Q

transdermal

A

patch: drug that is absorbed through the skin

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31
Q

parenteral

A
"Injected:
Intradermal: within the skin
Intramuscular: within the muscle
Itravenous: into the vein
Subcutaneous: just under the skin"
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32
Q

A

A

Assesment/ Analysis

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33
Q

ADL

A

Activities of daily living

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34
Q

BP

A

Blood pressure

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35
Q

CC

A

Chief complaint

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36
Q

c/o

A

Complaint of

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37
Q

CP

A

Chest pain

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38
Q

D/C

A

Discontinue

39
Q

⬇️

A

Decrease/ decreasing

40
Q

Dx

A

Diagnosis

41
Q

<-o

A

Male

42
Q

t

O

A

Female

43
Q

H&P

A

History and physical

44
Q

Ht

A

Height

45
Q

Hx

A

Personal medical history

46
Q

ICU

A

Intensive care unit

47
Q

⬆️

A

Increase/ increasing

48
Q

IP

A

Inpatient

49
Q

L in a circle

A

Left

50
Q

NKA

A

No known allergies

51
Q

NKDA

A

No known drug allergies

52
Q

O slashed

A

None

53
Q

OP

A

Outpatient

54
Q

OR

A

Operating room

55
Q

P

A

Pulse

56
Q

PE

A

Physical examination

57
Q

PI

A

Present illness

58
Q

postop

A

Recovery room

59
Q

preop

A

Preoperating area

60
Q

pt

A

Patient

61
Q

Px

A

Physical examination

62
Q

R

A

Respirations

63
Q

R in circle

A

Right

64
Q

R/O

A

Rule out

65
Q

ROM

A

Range of motion

66
Q

ROS

A

Review of symptoms

67
Q

SOB

A

Shortness of breath

68
Q

S

A

Signs

69
Q

Sx

A

Symptoms

70
Q

T

A

Temp

71
Q

Tx

A

Treatment

72
Q

VS

A

Vital signs

73
Q

WNL

A

Within normal limits

74
Q

Wt.

A

Weight

75
Q

_

a

A

Before

76
Q

B in circle

A

Bilateral

77
Q

b.i.d.

A

Twice a day

78
Q

_

c

A

With

79
Q

d.

A

Day

80
Q

h.

A

Hour

81
Q

_

p

A

After

82
Q

_

p.c.

A

After meals

83
Q

p.o.

A

By mouth

84
Q

p.r.n

A

As needed

85
Q

q.

A

Each or every

86
Q

q.d.

A

Every day

87
Q

q.h.

A

Every hour

88
Q

q.i.d.

A

4 times a day

89
Q

Rx

A

Prescription

90
Q

stat.

A

Immediately

91
Q

t.i.d.

A

Three times a day

92
Q

_

s

A

Without

93
Q

wk

A

Week

94
Q

yr

A

Year

95
Q

_

x

A

Times or for