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Unit 2 Flashcards

1
Q

Content of problem-oriented medical record. (POMR)

A 
List of patient problems
Database
Series of status (progress notes) written in SOAP note format.
  Initial
  Interim
  Discharge
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2
Q

a or ~a

A

Before, ante

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3
Q

AAROM

A

Active assist range of motion

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4
Q

Abduct or Abd

A

Abduction

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5
Q

ACL

A

Anterior cruciate ligament

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6
Q

AROM/A-ROM

A

Active range of motion

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7
Q

Add

A

Adduction

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8
Q

ADL

A

Activity of daily living

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9
Q

AFO

A

Ankle foot orthosis

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10
Q

AK

A

Above the knee

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11
Q

AKA

A

Above knee amputation

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12
Q

Amb

A

Ambulate

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13
Q

ASHD

A

Arteriosclerotic heart disease

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14
Q

ASIS

A

Anterior Superior Iliac Spine

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15
Q

(B), bilat or bil

A

Bilateral

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16
Q

BID

A

Twice daily

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17
Q

BIW

A

Twice weekly

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18
Q

BK

A

Below knee

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19
Q

BKA

A

Below knee amputation

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20
Q

BLE, BUE

A

Bilateral lower extremities, bilateral upper extremities

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21
Q

BP

A

Blood pressure

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22
Q

BPM

A

Beats per min

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23
Q

B/S

A

Bedside

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24
Q

CA

A

Cancer

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25
Q

CABG

A

Coronary artery bypass graft

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26
Q

CAD

A

Coronary artery disease

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27
Q

Card rehab

A

Cardiac rehabilitation

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28
Q

Cardio

A

Cardiology

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29
Q

CHF

A

Congestive heart failure

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30
Q

Contra

A

Against

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31
Q

CPM

A

Continuous passive motion

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32
Q

CVD

A

Cardiovascular disease

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33
Q

CXR

A

Chest X-ray

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34
Q

DC, dc, d’cont

A

Discontinue

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35
Q

D/c

A

Discharge

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36
Q

D&V

A

Diarrhea and vomiting

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37
Q

Dec, decr, or |

A

Decreased

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38
Q

Dep

A

Dependent

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39
Q

DF

A

Dorsiflexion

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40
Q

dx

A

Diagnosis

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41
Q

DM

A

Diabetes mellitus

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42
Q

DME

A

Durable medical equipment

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43
Q

Doc/docu

A

Document

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44
Q

DP

A

Dorsalis pedis

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45
Q

DRG

A

Diagnosis related group

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46
Q

D/T, d/t

A

Due to

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47
Q

DTR

A

Deep tendon reflex

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48
Q

DVT

A

Deep venous thrombus

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49
Q

Ea

A

Each

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50
Q

ELOS

A

Estimated length of stay

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51
Q

Ext

A

Extension

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52
Q

ER and IR

A

External rotation, internal rotation

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53
Q

FWB

A

Full weight bearing

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54
Q

Flx

A

Flexion

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55
Q

Fx or fx

A

Fracture

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56
Q

GSW

A

Gun shot wound

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57
Q

GT

A

Gait training

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58
Q

HA

A

Headache

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59
Q

HS

A

Hamstring

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60
Q

Hb

A

Hemoglobin

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61
Q

HBP

A

High blood pressure

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62
Q

HcL

A

Hydrochloric acid

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63
Q

HD

A

Heart disease

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64
Q

Hemi

A

Hemiplegia

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65
Q

HEP

A

Home exercise program

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66
Q

HgB

A

Hemoglobin

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67
Q

HKO

A

Hip-knee orthosis (splint)

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68
Q

HNP

A

Herniated nucleus pulposus

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69
Q

H/O

A

History of

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70
Q

HOB

A

Head of bed

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71
Q

Hosp

A

Hospital

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72
Q

HP

73
Q

HR

A

Heart rate

74
Q

Hr/hrs/hr/h

75
Q

Ht/ht

76
Q

HTN

A

Hypertension

77
Q

Hx

78
Q

IDDM

A

Insulin dependent diabetes mellitus

79
Q

JCHAO

A

Joint commission on accreditation of healthcare organization

80
Q

KAFO

A

Knee ankle foot orthosis

81
Q

LAQ

A

Long arc quad

82
Q

LB

83
Q

LBKA

A

Left below the knee amputations

84
Q

LBP

A

Low back pain

85
Q

LBQC

A

Large based quad cane

86
Q

LE

A

Lower extremity

87
Q

LLE

A

Left lower extremity

88
Q

LOS

A

Length of stay

89
Q

Lt, (L), L

90
Q

LTC

A

Long term care

91
Q

LTG

A

Long term goal

92
Q

LUE

A

Left upper extremity

93
Q

LUL

A

Left upper lobe

94
Q

LUQ

A

Left upper quadrant

95
Q

LVN

A

Licensed vocational nurse

96
Q

MI

A

Myocardial infarction

97
Q

Min

98
Q

Min A

A

Minimal assistance

99
Q

Mod

100
Q

MVA

A

Motor vehicle accident

101
Q

Na

102
Q

N/A

A

Not applicable

103
Q

NaCl

A

Sodium chloride

104
Q

NSAIDS

A

Non-steroidal anti-inflammatory drug

105
Q

NWB

A

Non weight bearing

106
Q

OA

A

Osteoarthritis

107
Q

OOB

A

Out of bed

108
Q

OP

A

Out patient

109
Q

ORIF

A

Open reduction and internal fixation

110
Q

O2

111
Q

O2Sat

A

Oxygen saturation

112
Q

OT

A

Occupational therapy

113
Q

p–

114
Q

PMH

A

Past medical history

115
Q

po

116
Q

PRE

A

Progressive resistive exercise

117
Q

PRN/prn

118
Q

Prog

119
Q

PROM/P-ROM

A

Passive range of motion

120
Q

Pulse ox

A

Pulse oximeter

121
Q

PVD

A

Peripheral vascular disease

122
Q

PWB

A

Partial weight bearing

123
Q

q

124
Q

QC 4-cane

125
Q

Quad

A

Quadriplegic

126
Q

Quads

A

Quadriceps

127
Q

(R), Rt.

128
Q

RA

A

Rheumatoid arthritis

129
Q

RE

A

Right extremity

130
Q

R-Hemi

A

Right sided Hemiplegia

131
Q

RLE

A

Right lower extremity

132
Q

R/o

133
Q

ROM

A

Range of motion

134
Q

RR

A

Respiratory rate

135
Q

RUE

A

Right upper extremity

136
Q

RW

A

Rolling walker

137
Q

Rx

A

Prescription

138
Q

SBQC

A

Short based quad cane

139
Q

SCI

A

Spinal cord injury

140
Q

SI joint or SIJ

A

Sacroiliac joint

141
Q

SLP

A

Speech language pathology

142
Q

2 degree

A

Secondary or due to

143
Q

SNF

A

Skilled nursing facility

144
Q

SOAP

A

Subjective, objective assessment plan

145
Q

S/P

A

Status post

146
Q

STG

A

Short term goal

147
Q

STM

A

Short term memory or soft tissue massage

148
Q

SW

A

Standard walker

149
Q

Tachy

A

Tachycardia

150
Q

TB

A

Tuberculosis

151
Q

TBand

152
Q

TBI

A

Traumatic brain injury

153
Q

TDWD

A

Touch down weight bearing

154
Q

TED

A

Anti embolism stockings

155
Q

THA

A

Total hip arthroplasty

156
Q

TKA

A

Total knee argtroplasty

157
Q

Ther.Ex.

A

Therapeutic exercise

158
Q

TIA

A

Transient Ischemic attack

159
Q

TID

160
Q

TIW

161
Q

Tib-fib/tib/fib

A

Tibia and fibula

162
Q

TTWB

A

Toe touch weight bearing

163
Q

Tx

164
Q

UE

A

Upper extremity

165
Q

Unilat

A

Unilateral

166
Q

US

A

Ultrasound

167
Q

V.O.

A

Verbal order

168
Q

VS

A

Vital signs

169
Q

WB

A

Weight bearing

170
Q

WBAT

A

Weight bearing as tolerated

171
Q

WBC

A

White blood count

172
Q

W/C

A

Wheelchair

173
Q

C-, w, or w/

A

With; from Latin word contigo

174
Q

S- or w/o

A

Without; from Latin word sine

175
Q

WNL

A

Within normal limits

176
Q

X-rays

A

Roentgens Rays

177
Q

Yr

178
Q

YO

179
Q

YTD

A

Year to date

PTA (7 decks)

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