Unit 2 Flashcards
Content of problem-oriented medical record. (POMR)
List of patient problems Database Series of status (progress notes) written in SOAP note format. Initial Interim Discharge
a or ~a
Before, ante
AAROM
Active assist range of motion
Abduct or Abd
Abduction
ACL
Anterior cruciate ligament
AROM/A-ROM
Active range of motion
Add
Adduction
ADL
Activity of daily living
AFO
Ankle foot orthosis
AK
Above the knee
AKA
Above knee amputation
Amb
Ambulate
ASHD
Arteriosclerotic heart disease
ASIS
Anterior Superior Iliac Spine
(B), bilat or bil
Bilateral
BID
Twice daily
BIW
Twice weekly
BK
Below knee
BKA
Below knee amputation
BLE, BUE
Bilateral lower extremities, bilateral upper extremities
BP
Blood pressure
BPM
Beats per min
B/S
Bedside
CA
Cancer
CABG
Coronary artery bypass graft
CAD
Coronary artery disease
Card rehab
Cardiac rehabilitation
Cardio
Cardiology
CHF
Congestive heart failure
Contra
Against
CPM
Continuous passive motion
CVD
Cardiovascular disease
CXR
Chest X-ray
DC, dc, d’cont
Discontinue
D/c
Discharge
D&V
Diarrhea and vomiting
Dec, decr, or |
Decreased
Dep
Dependent
DF
Dorsiflexion
dx
Diagnosis
DM
Diabetes mellitus
DME
Durable medical equipment
Doc/docu
Document
DP
Dorsalis pedis
DRG
Diagnosis related group
D/T, d/t
Due to
DTR
Deep tendon reflex
DVT
Deep venous thrombus
Ea
Each
ELOS
Estimated length of stay
Ext
Extension
ER and IR
External rotation, internal rotation
FWB
Full weight bearing
Flx
Flexion
Fx or fx
Fracture
GSW
Gun shot wound
GT
Gait training
HA
Headache
HS
Hamstring
Hb
Hemoglobin
HBP
High blood pressure
HcL
Hydrochloric acid
HD
Heart disease
Hemi
Hemiplegia
HEP
Home exercise program
HgB
Hemoglobin
HKO
Hip-knee orthosis (splint)
HNP
Herniated nucleus pulposus
H/O
History of
HOB
Head of bed
Hosp
Hospital