DOCUMENTATION Flashcards

1
Q

ABG

A

arterial blood gases

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2
Q

AMA

A

against medical advice

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3
Q

amb

A

Ambulation

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4
Q

ABI

A

acquired brain injury

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5
Q

ASA

A

aspirin

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6
Q

ALS

A

amyotrophic lateral sclerosis

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7
Q

BUN

A

blood urea nitrogen (blood test)

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8
Q

CA

A

cancer / carcinoma

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9
Q

c/o

A

complains of

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10
Q

CAT

A

computerized axial tomography

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11
Q

DNR

A

do not resuscitate

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12
Q

CC, C/C

A

chief complaint

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13
Q

DM

A

diabetes mellitus

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14
Q

Dx

A

diagnosis

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15
Q

CSF

A

cerebrospinal fluid

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16
Q

DOE

A

dyspnea on exertion

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17
Q

CMV

A

cytomegalovirus

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18
Q

A:

A

assessment

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19
Q

ac

A

before meals

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20
Q

ad lib

A

at discretion

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21
Q

D/C

A

discontinued or discharged

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22
Q

FH

A

family history

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23
Q

hs

A

at bed time

24
Q

Hx

A

history

25
Q

GSW

A

gunshot wound

26
Q

fx

A

fracture

27
Q

h/o

A

history of

28
Q

HOB

A

head of bed

29
Q

IRDS

A

infant respiratory distress syndrome

30
Q

KAFO

A

knee-ankle-foot orthosis

31
Q

KUB

A

kidney-ureter-bladder

32
Q

LOC

A

loss of consciousness

33
Q

nn

A

nerve

34
Q

LBBB

A

left bundle branch block

35
Q

LBP

A

low back pain

36
Q

noc

A

night, at night

37
Q

O:

A

objective

38
Q

od

A

once daily

39
Q

ORIF

A

open reduction, internal fixation

40
Q

NSR

A

normal sinus rhythm

41
Q

P:

A

plan, intervention plan, plan of care

42
Q

para

A

paraplegia

43
Q

q

A

every

44
Q

qid

A

four times a day

45
Q

re:

A

regarding

46
Q

PRE

A

progressive-resistive exercise

47
Q

r/o, R/O

A

ruled out

48
Q

TIS

A

transient ischemic attack

49
Q

tid

A

three times daily

50
Q

A

to progressing toward, approaching primary

51
Q

w/c

A

wheelchair

52
Q

~ or ≈

A

approximately

53
Q

WNL

A

within normal limits

54
Q

VD

A

venereal disease

55
Q

SOB

A

shortness of breath