Documentation Flashcards

1
Q

ABG

A

Arterial blood gases

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2
Q

ALS

A

amyotrophic lateral sclerosis

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3
Q

AMA

A

Against medical advice

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4
Q

Amb

A

Ambulation

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5
Q

Ant

A

Anterior

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6
Q

BOS

A

Base of support

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7
Q

CA

A

Cancer

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8
Q

CABG

A

Coronary artery bypass graft

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9
Q

CG

A

Contact guard

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10
Q

CN

A

Cranial nerve

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11
Q

CT

A

Computed tomography

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12
Q

CVA

A

Cerebrovascular accident

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13
Q

d/c

A

Discontinue

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14
Q

DOA

A

Dyspnea on exertion

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15
Q

EEG

A

Electroencephalogram

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16
Q

EENT

A

Ears, eyes, Nose, throat

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17
Q

EMG

A

Electromyography

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18
Q

EtOH

A

Alcohol

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19
Q

FWW

A

Front wheeled walker

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20
Q

GSW

A

gun shot wound

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21
Q

H & P

A

History and physical

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22
Q

Hct

A

Hematocrit

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23
Q

Hgb

A

Hemoglobin

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24
Q

HOB

A

Head of bed

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25
Q

I

A

independent

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26
Q

IABL

A

Instumental activites of daily living

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27
Q

IDDM

A

Insulin dependent diabetes mellitus

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28
Q

I&O

A

Intake and output

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29
Q

JCAHO

A

Joint commision on accreditation of health car organization

30
Q

LMN

A

Lower motor neuron

31
Q

LOB

A

Loss of balance

32
Q

LTG

A

long term goal

33
Q

MCA

A

Middle cerebral artery

34
Q

NG

A

Nasogastric tube

35
Q

NIDDM

A

Non insulin dependent dibetes mellitus

36
Q

NPO

A

Nothing by mouth

37
Q

NSR

A

Normal sinus rhythm

38
Q

Oriented x 3

A

oriented to person place and time

39
Q

OOB

A

out of bed

40
Q

ORIF

A

Open reduction internal fixation

41
Q

PD

A

parkinson’s disease

42
Q

PO

A

By mouth

43
Q

POD

A

post operative day

44
Q

PRN

A

As needed

45
Q

Px

A

prognosis

46
Q

q

A

every

47
Q

qh

A

every hour

48
Q

QID

A

four times a day

49
Q

RA

A

Rheumatoid arthritis

50
Q

R/O

A

Rule out

51
Q

RR

A

Respiratory rate

52
Q

RRR

A

Regular rate and rhythm

53
Q

SBA

A

Stand by assist

54
Q

SOA

A

Short of air

55
Q

SOB

A

Shortness of breath

56
Q

s/p

A

Status post

57
Q

STG

A

Short term goal

58
Q

Sx

A

symptoms

59
Q

TBI

A

Traumatic brain injury

60
Q

THA

A

Total hip arthroplasty

61
Q

THR

A

Total hip replacement

62
Q

TIA

A

Tansient ischemic attack

63
Q

TKA

A

Total knee arthroplasty

64
Q

TKR

A

Total knee replacement

65
Q

UMN

A

upper motor neuron

66
Q

VS

A

Vital signs

67
Q

w/c

A

Wheelchair

68
Q

1 degree

A

primary

69
Q

2 degree

A

secondary

70
Q

ALS

A

amyotrophic lateral sclerosis

71
Q

CABG

A

Coronary artery bypass graft

72
Q

IADL

A

Instumental activites of daily living