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CMA: Techniques > Medical Record & Health History > Flashcards

Medical Record & Health History Flashcards

Chapter 1

1
Q

Medical Record

A

a written record of important information regarding a patient, their care, and progress of their condition.

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2
Q

HIPAA

A

Health Insurance Portability and Accountability Act

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3
Q

What is HIPPA?

A
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4
Q

Symptom

A

a symptom is any change in the body or its functioning that indicates the presence of disease.

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5
Q

Subjective symptom

A
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6
Q

Objective symptom

A
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7
Q

Charting

A

the process of making written entries about a patient in the medical records.

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8
Q

Patient

A

an individual receiving medical care.

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9
Q

Review of Systems (ROS)

A
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10
Q

Diagnosis

A

the scientific method of determining and identifying a patient’s condition.

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11
Q

Prognosis

A

the probable course and outcome of a patient’s condition and the patient’s prospects for recovery.

an assumption of what the symptoms are representing.

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12
Q

Chief Complaint (CC)

A
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13
Q

New patient vs. Established patient

A
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14
Q

Medical Office Administrative Docs

A
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15
Q

Dysuria

A

difficult or painful urination.

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16
Q

Polyuria

A

increased output of urine.

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17
Q

admin

A

administer (med. abbreviation)

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18
Q

amt

A

amount (med. abbreviation)

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19
Q

approx

A

approximately (abbreviation)

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20
Q

appt

A

appointment (med. abbreviation)

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21
Q

ASA

A

acetylsalicylic acid / aspirin (med. abbreviation)

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22
Q

ASAP

A

as soon as possible (med. abbreviation)

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23
Q

BC

A

birth control (med. abbreviation)

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24
Q

bid

A

twice a day (med. abbreviation)

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25
Q

BM

A

bowel movement (abbreviation)

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26
Q

BP

A

blood pressure (med. abbreviation)

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27
Q

BPM

A

beats per minute (med. abbreviation)

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28
Q

BS

A

blood sugar (med. abbreviation)

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29
Q

c̅

A

with (med. abbreviation)

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30
Q

CC

A

chief complaint (med. abbreviation)

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31
Q

CMA (AAMA)

A

certified medical assistant (American Association of Medical Assistants)

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32
Q

CCMA (NHA)

A

certified clinical medical assistant (National Healthcareer Association)

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33
Q

c/o

A

complains of (med. abbreviation)

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34
Q

d

A

day (med. abbreviation)

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35
Q

/d

A

per day (med. abbreviation)

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36
Q

d/c

A

discontinue (med. abbreviation)

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37
Q

DOB

A

date of birth (med. abbreviation)

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38
Q

DVA

A

distance visual acuity (med. abbreviation)

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39
Q

ED

A

emergency department (med. abbreviation)

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40
Q

EDD

A

expected date of delivery (med. abbreviation)

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41
Q

F/U

A

follow up (med. abbreviation)

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42
Q

Fx

A

fracture (med. abbreviation)

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43
Q

GYN

A

gynecology (med. abbreviation)

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44
Q

h | hr

A

hour (med. abbreviation)

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45
Q

H/A

A

headache (med. abbreviation)

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46
Q

HBP

A

high blood pressure (med. abbreviation)

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47
Q

Hep B

A

hepatitis B vaccine (med. abbreviation)

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48
Q

H₂O

A

water (med. abbreviation)

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49
Q

HR

A

heart rate (med. abbreviation)

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50
Q

ht

A

height (med. abbreviation)

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51
Q

ID

A

interdermal (med. abbreviation)

52
Q

IM

A

intramuscular (med. abbreviation)

53
Q

IV

A

intravenous (med. abbreviation)

54
Q

LBP

A

lower back pain (med. abbreviation)

55
Q

LMP

A

last menstrual period (med. abbreviation)

56
Q

med, meds

A

medication, medications (med. abbreviation)

57
Q

min

A

minute (med. abbreviation)

58
Q

MMR

A

measles, mumps, and rubella (med. abbreviation)

59
Q

N/A

A

not applicable (med. abbreviation)

60
Q

N/C

A

no complaints (med. abbreviation)

61
Q

neg

A

negative (med. abbreviation)

62
Q

NKA

A

no known allergies (med. abbreviation)

63
Q

NKDA

A

no known drug allergies (med. abbreviation)

64
Q

N&V

A

nausea and vomiting (med. abbreviation)

65
Q

NVA

A

near visual acuity (med. abbreviation)

66
Q

OTC

A

over the counter (nonprescription medication)
(med. abbreviation)

67
Q

OV

A

office visit (med. abbreviation)

68
Q

P

A

pulse (med. abbreviation)

69
Q

pc

A

after meals (med. abbreviation)

70
Q

per

A

by or through (med. abbreviation)

71
Q

po | PO

A

by mouth (med. abbreviation)

72
Q

pos

A

positive (med. abbreviation)

73
Q

postop

A

postoperative (after surgery)
(med. abbreviation)

74
Q

preop

A

preoperative (before surgery)
(med. abbreviation)

75
Q

prn

A

as needed (med. abbreviation)

76
Q

Pt | pt

A

patient (med. abbreviation)

77
Q

qh

A

every hour (med. abbreviation)

78
Q

qid

A

four times a day (med. abbreviation)

79
Q

QNS

A

quantity not sufficient (med. abbreviation)

80
Q

R

A

respiration (med. abbreviation)

81
Q

RMA

A

registered medical assistant

82
Q

Rx

A

prescription (med. abbreviation)

83
Q

s̅

A

without (med. abbreviation)

84
Q

subcut

A

subcutaneous (med. abbreviation)

85
Q

SOB

A

shortness of breath (med. abbreviation)

86
Q

STAT

A

immediately (med. abbreviation)

87
Q

T

A

temperature (med. abbreviation)

88
Q

tab, tabs

A

tablet, tablets (med. abbreviation)

89
Q

temp

A

temperature (med. abbreviation)

90
Q

tid

A

three times a day (med. abbreviation)

91
Q

WNL

A

within normal limits (med. abbreviation)

92
Q

w/o

93
Q

wt

A

weight (med. abbreviation)

94
Q

abd

A

abdomen (med. abbreviation)

95
Q

EENT

A

eye, ear, nose, and throat (med. abbreviation)

96
Q

GI

A

gastrointestinal (med. abbreviation)

97
Q

Ⓛ | lt

A

left (med. abbreviation)

98
Q

LA (circled)

A

left arm (med. abbreviation)

99
Q

LL (circled)

A

left leg (med. abbreviation)

100
Q

LLQ

A

lower left quadrant (med. abbreviation)

101
Q

LRQ

A

lower right quadrant (med. abbreviation)

102
Q

LUQ

A

left upper quadrant (med. abbreviation)

103
Q

® | rt

A

right (med. abbreviation)

104
Q

RA (circled)

A

right arm (med. abbreviation)

105
Q

RL (circled)

A

right leg (med. abbreviation)

106
Q

RLQ

A

right lower quadrant (med. abbreviation)

107
Q

RUQ

A

right upper quadrant (med. abbreviation)

108
Q

Dx

A

diagnosis (med. abbreviation)

109
Q

H/O

A

history of (med. abbreviation)

110
Q

H&P

A

history and physical (med. abbreviation)

111
Q

Hx

A

history (med. abbreviation)

112
Q

PE | Px

A

physical examination (med. abbreviation)

113
Q

Sx

A

symptoms (med. abbreviation)

114
Q

Tx

A

treatment (med. abbreviation)

115
Q

CA

A

cancer (med. abbreviation)

116
Q

CAD

A

coronary artery disease (med. abbreviation)

117
Q

CHF

A

congestive heart failure (med. abbreviation)

118
Q

COPD

A

chronic obstructive pulmonary disease (med. abbreviation)

119
Q

DM

A

diabetes mellitus (med. abbreviation)

120
Q

HTN

A

hypertension (med. abbreviation)

121
Q

IBS

A

irritable bowel syndrome (med. abbreviation)

122
Q

OM

A

otitis media (infection in the middle ear)
(med. abbreviation)

123
Q

TB

A

tuberculosis (med. abbreviation)

124
Q

URI

A

upper respiratory infection (med. abbreviation)

125
Q

UTI

A

urinary tract infection (med. abbreviation)

126
Q

mL

A

milliliter (med. abbreviation)

CMA: Techniques (7 decks)

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