Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Chpt. 2 Abbreviation
| Term | Definition |
|---|---|
| CCU | coronary care unit |
| ECU | |
| ER | |
| ED | |
| ICU | |
| PICU | |
| NICU | |
| SICU | |
| PACU | |
| L&D | labor and delivery |
| OR | |
| post-op | |
| pre-op | |
| Soap | Subjective |
| sOap | Objective |
| soAp | Assessment |
| soaP | Plan |
| A soap note is | A pattern used in writing medical notes and a way of thinking |
| diagnosis | the identification of the actual problem |
| differential diagnosis | a list of possible causes of the patients problem or complaint |
| CC | Chief Concern |
| acute | it just started recently or is a sharp, severe symptom |
| chronic | it has been going on for a while now |
| exacerbation | it is getting worse |
| abrupt | all of a sudden |
| febrile | to have a fever |
| afebrile | to not have a fever |
| malaise | not feeling well |
| progressive | more and more each day |
| symptom | something a patient feels |
| noncontributory | not related to this specific problem |
| lethargic | a decrease in level of consciousness; in a medical record, this is generally an indication that the patient is really sick |
| genetic/hereditary | it runs in the family |
| alert | able to answer questions; responsive; interactive |
| oriented | being aware of who he or she is, where he or she is, and the current time; a patient who is aware of all three is "oriented x 3" |
| marked | it really stands out |
| unremarkable | another way of saying normal |
| auscultation | to listen |
| percussion | to hit something and listen to the resulting sound or feel for the resulting vibration; drums are a percussion instrument |
| palpation | to feel |
| impression | another way of saying assessment |
| benign | safe |
| malignant | dangerous; a problem |
| degeneration | to be getting worse |
| remission | to get better or improve; most often used when discussing cancer; remission does not mean cure |
| idiopathic | no known specific cause; it just happens |
| localized | stays in a certain part of the body |
| systemic/generalized | all over the body (or most of it) |
| prognosis | the chances for things getting better or worse |
| occult | hidden |
| lesion | diseased tissue |
| recurrent | to have again |
| sequela | a problem resulting from a disease or injury |
| pending | waiting for |
| pathogen | the organism that causes the problem |
| morbidity | the risk for being sick |
| mortality | the risk for dying |
| etiology (EET-ee-AWL-oh-jee) | the cause |
| disposition | what happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, the ICU, normal hospital bed) |
| discharge | literally to unload; it has two meanings: to send home or fluid coming out of a part of your body |
| palliative | treating the symptoms, but not actually getting rid of the cause |
| observation | watch, keep an eye on |
| reassurance | to tell the patient that the problem is not serious or dangerous |
| supportive care | to treat symptoms and make the patient feel better |
| sterile | extremely clean, germ-free conditions; especially important during medical procedures and surgery |
| prophylaxis | preventive treatment |
| proximal | closer to the center |
| distal | farther away from center |
| lateral | out to the side |
| medial | toward the middle |
| ventral/ antral/ anterior | the front |
| dorsal/ posterior | the back |
| cranial | toward the top |
| caudal | toward the bottom |
| superior | above |
| inferior | below |
| prone | lying down on belly |
| supine | lying down on back |
| contralateral | opposite side |
| ipsilateral | same side |
| unilateral | one side |
| bilateral | both sides |
| dorsum | the top of the hand or foot |
| plantar | the sole of the foot |
| palmar | the palm of the hand |
| sagittal | plane left to right |
| coronal | plane divides front to back |
| transverse | divides body from top and bottom |
| physician | a skilled health care provider who attended and graduated medical school MD or DO |
| pediatrician | a physician with special training in caring for children |
| surgeon | a physician qualified to treat patients surgically, that is, by means of operation or invasive procedure |
| anesthesiologist | a physician with specialized training in pain sedation and pain control |
| epidemiologist | a specialist in the study of the causes and distribution of diseases n populations and the use of this data to enhance public health |
| physician assistant (PA) | a midlevel health care provider who works under the license of a supervising physician; requires postgraduate training |
| nurse practitioner (NP) | a nurse with postgraduate training that serves as a midlevel health care provider; works under the license of a supervising physician |
| emergency medical technician (EMT) | specially trained in the emergency care of a patient before and/or during transport to medical facility |
| speech therapist | specially trained in evaluating and treating problems with speech and/or swallowing |
| occupational therapist | specially trained in evaluating and treating problems with performing daily activities at home, school, or work |
| physical therapist | specially trained in evaluating and treating physical impairments including disabilities or recovery from an injury |
| respiratory therapist | specially trained in treating patient's respiratory issues under the guidance of a health are provider |
| dietician | specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan |
| licensed practical nurse (LPN) licensed vocational nurse (LVN) | trained and certified to provide basic care to patient |
| registered nurse (RN) | an advanced level nurse who has a completed an associate's or bachelor's degree; often assists with patient care planning and patient eductaion |
| medical assistant | trained to carry out basic administrative and clinical tasks under the guidance of a health care provider |
| pathologist | a physician with special training in both evaluating the causes and effects of disease and in laboratory medicine |
| medical laboratory technician | trained in performing laboratory testing on body fluids |
| phlebotomist | trained in the removal of blood from the body for diagnostic or therapeutic purposes |
| radiologist | a physician specially trained in evaluating images of the body to diagnose illness or injury |
| radiology technician | trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider |
| ultrasonographer | trained on performing ultrasound imaging on a patient |
| pharmacist | trained and licensed in preparing and dispensing medicine |
| pharmacy technician | trained to assist a pharmacist with pharmacy-related tasks |
| patient service coordinator | handles administrative tasks and coordinates patient care |
| medical transcriptionist | trained to converting the voice-recorded dictation of health care provider into text format |
| Chief complaint | the main reason for the patients visit |
| History of present illness | the story of the patient's problem |
| Review of systems | Description of individual body systems in order to discover any symptoms not directly related to the main problem |
| past medical history | other significant past illnesses, like high blood pressure, asthma, or diabetes |
| past surgical history | any of the patients past surgeries |
| family history | any significant illnesses that run in the patients family |
| social history | a record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health |
| VS | vital signs |
| T | temperature |
| BP | blood pressure |
| HR | heart rate |
| RR | respiratory rate |
| Ht | height |
| Wt | weight |
| BMI | body mass index |
| I/O | intake/ output |
| Dx | diagnosis |
| DDx | differential diagnosis |
| Tx | treatment |
| Rx | prescription |
| H&P | history and physical |
| Hx | history |
| CC | Chief complaint (the main reason for the visit) |
| HPI | History of present illness ( the story of the symptoms) |
| ROS | review of systems (anything else not directly related to the chief complaint) |
| PMHx | past medical history |
| FHx | Family history |
| NKDA | no known drug allergies |
| PE | physical exam |
| Pt | pateint |
| y/o | years old |
| h/o | history of |
| PCP | primary care provider |
| f/u | follow up |
| SOB or SOA | shortness of breath or shortness of air |
| HEENT | head, eyes, ears, nose, and throat |
| PERRLA | pupils are equal, round, and reactive to light and accommodation |
| NAD | no acute distress ( the patient does not display any intense symptoms) |
| CV | cardiovasular |
| RRR | regular rate and rhythm |
| CTA | clear to auscultation (description of normal sounding lungs) |
| WDWN | well developed, well nourished |
| A&O | alert and oriented |
| WNL | within normal limits |
| NOS and NEC | not otherwise specified and not elsewhere classified NOTE: NOS and NEC are catch-alls for diagnoses that don't quite fit any specific cause ( for example, "rash NOS") |
| PO | per os (by mouth) |
| NPO | nil per os (nothing by mouth) |
| PR | per rectum (anal) |
| IM | intramuscular |
| SC | subcutaneous (under the skin) |
| IV | intravenous |
| CVL | central venous line |
| PICC | peripherally inserted central catheter |
| Sig | instructions short for signa, from Latin, for label |
| BID | twice daily, from the Latin phrase bis in die, which means "two in a day" |
| TID | three times daily, from the Latin phrase ter in die, which means "three in a day" |
| Q | every x, example Q4hr would mean every 4 hours or Q3 days would be every 3 days |
| QD* | daily, from the Latin phrase quaque die, with means "each day" *no longer used |
| QID* | four times daily, from the Latin phrase quater in die, which means "four in a day" |
| QHS | at night, from the Latin phrase quaque hora somni, which means each night at the hour of sleep" |
| AC | before meals, from the Latin phrase ante cibum, which means "before food" |
| PC | after meals, from the Latin phrase post cibum, which means "after food" |
| prn | as needed, from the Latin phrase per re nata, which means "as the need arises" |
| ad lib | as desired |
Created by:
avonessenivytech.edu