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60 Cards in this Set

  • Front
  • Back
XR
x-ray
>:
greater than
arrow up
increase
WNL
within normal limits
<:
less than
arrow down
decrease
triangle
change
CX or CXN
contraction
CC
chief complaint
pt
patient
MHX
basis for treatment rendered by the physician
UCHD
usual childhood illnesses
source-oriented medical record (SOMR)
a traditional or conventional method of charting, consists of chronological set of notes for each visit, beginning w/ the patients 1st visit
problem-oriented medical record(POMR)
a more efficient way of keeping chart notes, used alot by clinics or any medical practice where more than one physician may see the patient. Calls for a list of problems to be made, dated, and numbers assigned to them
computer modified records
ties both methods together, can be viewed 24 hours a day
c with a line over it
with
q.d
everyday
qid
4x a day (on a prescription)
D/C
discharge, discontinue
cc
ml
PEERLA
pupils equal, round, reactive to light and accomodation
PT
physical therapy
BP or B/P
blood pressure
CBC
complete blood count
CPE
complete physical exam
D & C
dilation and curettage
dx
diagnosis
ECG, EKG
electrocardiogram
EEG
electroencephalogram
ER
emergency room
GI
gastrointestinal
GU
genitourinary
URI
upper respiratory infection
UTI
urinary tract infection
GYN
gynecology
HEENT
head, eyes, ears, nose and throat
HEENT
head, eyes, ears, nose and throat
I & D
incision and drainage
L or L with a circle around it
left
MI
myocardial infarction
N & V
nausea and vomiting
NVD
nausea, vomiting, and diarrhea
OPD
outpatient department
OR
operating room
P
pulse
Hx
history
Rx
prescription or treatment
Tx
treatment
Fx
fracture
R with a circle around it
right
R
respiration
ROM
range of motion
ROS
review of systems
- s with a line over it
s
without
SOAP
subjective, objective, assessment, plan
SOB
short of breath
T
temperature
T & A
tosillectomy and adenoidectomy
<:
less than
arrow down
decrease