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MedicalTerminology2
Introduction to Health Records
| Term | Definition |
|---|---|
| pathologist | physician with special training in both evaluating causes and effects of disease and in lab medicine |
| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| patient service coordinator | handles administrative tasks and coordinates patient care |
| CCU | coronary care unit |
| ECU | emergency care unit |
| ED | emergency dept |
| PICU, NICU, SICU, PACU | (intensive care units for) pediatric, neonatal, surgical, post-anesthesia |
| L&D | labor and delivery |
| (B) | bilateral |
| VS | vital signs |
| T | temperature |
| RR | respiratory rate |
| I/O | intake/output (fluids taken in and produced) |
| Tx | treatment |
| CC | chief complaint |
| HPI | history of present illness |
| ROS | review of symptoms (anything else not directly related to chief complaint) |
| PMHx | past medical history |
| FHx | family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| h/o | history of |
| SOB/SOA | shortness of breath/air |
| HEENT | head eyes ears nose and throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodation (correctly constrict) |
| NAD | no acute distress |
| CV | cardiovascular |
| RRR | regular rate and rhythm (<3) |
| CTA | clear to auscultation (lungs) |
| WDWN | well developed, well nourished |
| A&O | alert and oriented |
| WNL | within normal limits |
| NOS | not otherwise specified |
| NEC | not elsewhere classified |
| PO | per os (by mouth) |
| NPO | nil per os (nothing by mouth) |
| PR | per rectum (anal) |
| IM | intramuscular |
| SC | subcutaneous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | Lat. signa "label" |
| BID | twice daily (Lat. bis in die) |
| TID | thrice daily (Lat. ter in die) |
| Q | every x |
| QHS | at night (Lat. quaque hora somni) |
| AC | before meals (Lat. ante cibum) |
| PC | after meals (Lat. post cibum) |
| prn | as needed (Lat. per re nata) |
| ad lib | as desired |