Question | Answer |
active voice | the subject of the sentence performs the action |
redundant | repetitive, being in excess |
passive voice | the subject of the sentence receives the action |
transcription | listening to dictation while typing into a written record |
proof reading | reviewing or reading printed, typed, and handwritten material to check for content and errors |
inactive | files for people who have not been seen for a specific period of time |
numeric | filing system which assigns numbers to each persons name |
closed | files for people who are no longer patients |
active | files for patients who are current patients |
archives | file or information that has been placed in storage |
triage | to determine the priority for handling patients with severe conditions and injuries. |
acute condition | illness or injury that comes upon the patient suddenly and requires treatment |
matrix | base upon which to build, for example, to develop a shape of format for the daily schedule |
wave | flexible scheduling in which each hour is divided into segments of time |
assessment | evaluation |
empathy | the ability to imagine how another person is feeling |
feedback | any response to a communication |
sympathy | feeling sorry for someone |
restating | directing the conversation back to a person by stating what they said in different terms |
reflective | directing the conversation back to a person by repeating the words |
assertive | the practice of declaring a point in a positive manner |
adm | admission, admit |
bx | biopsy |
c/o | complains of |
cc | chief complaint |
cpx | complete physicial exam |
d/c | discharge, discontinue |
dx | diagnosis |
FH | family history |
fu | follow-up |
fuo | fever of unknown origin |
lmp | last menstrual period |
n/c | no charge, no complaint |
pe | physical exam |
ph | prior history |
POMR | problem orientated medical records |
r/o | rule out |
ros | review of systems |
SOAP | subjective, objective, assessment, plan |
sob | short of breath |
sx | symptoms |
tx | treatment |
wnl | within normal limits |
pi | present illness |
rx | prescription |