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Chapter 2

Induction to health records

TermDefinition
1.SOB shortness of breath
2.HEENT Head, eyes ,ears ,nose and throat
3.NAD No acute distress
4.CV Cardiovascular
4.RRR Regular rate and rhythm
5.CTA Clear to auscultation
6.A&O Alert and oriented
7.Acute It just started or is a sharp severe symptom
8. Chronic It has been going on for a while now
9.exacerbation It is getting worse
10.abrupt All of a sudden
11.febrile To have a fever
12.afebrile To not have a fever
13. Malaise Not feeling well
14.progressive More and more each day
15.symptom Something a patient feels
16. Noncontributory Not related to this specific problem
17. Lethargic A decrease in level of consciousness
18.auscultation To listen
19.palpation To feel
20.impression Another way of saying assessment
21. Idiopathic No known specific cause
22.sequela A problem resulting from a disease or injury
23.pathogen The organism that causes the problem
24.morbidity The risk for being sick
25.mortality The risk of dying
26.etiology The cause
27.contralateral Opposite side
28.ipsilateral Same side
29.NKDA No known drug allergies
30.ROS Review of systems
Created by: AsiBac
 

 



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