Medical Records

Front 1

attending physician

Back 1

the phys responsible for the care of a hospitalized patient

Front 2

charting

Back 2

the process of documenting information about a pt in the medical record

Front 3

consultation report

Back 3

a narrative report of an opinion about a pt's condition by a practitioner other than the attending phys

Front 4

diagnosis

Back 4

the scientific method of determining and identifying a pt's condition

Front 5

diagnostic procedure

Back 5

a procedure performed to assist in the diagnosis, management, or treatment of a pt's condition

Front 6

discharge summary report

Back 6

a brief summary of the significant events of a pt's hospitalization

Front 7

electronic medical record (EMR)

Back 7

a med record on the computer

Front 8

familial

Back 8

occurring in or affecting members of a family more frequently than would be expected by chance

Front 9

health history report

Back 9

a collection of subjective data data about a pt

Front 10

home health care

Back 10

the provision of a med and non med care in a pt's home or place of residence

Front 11

informed consent

Back 11

consent given by a pt for a med procedure after he or she has been informed of the nature of his/her condition and the purpose of the procedure, and has been given an explanation of risks involved with the procedure, alternative treatments or procedures available

Front 12

inpatient

Back 12

a pt who has been admitted to a hospital for at least one overnight stay

Front 13

medical impressions

Back 13

conclusions drawn by the phys from an interpretation of data

Front 14

medical record

Back 14

a written record of important information regarding a pt including the care of the individual and the progress of the pt's condition

Front 15

medical record format

Back 15

the way a med record is organized, the two main types of a medical record formats are source-orientated and problem-orientated

Front 16

objective symptoms

Back 16

a symptom that can be observed by examiner

Front 17

paper-based pt record (PPR)

Back 17

med record in paper form

Front 18

pt

Back 18

individual receiving medical care

Front 19

physical exam

Back 19

an assessment of each part of the pt's body to obtain objective data about the pt that assists the phys in determining the pt's state of health

Front 20

physical exam report

Back 20

a report of objective data findings from the phys assessment of each body system

Front 21

problem

Back 21

any condition that requires further observation, diagnosis, management, or pt education

Front 22

prognosis

Back 22

the probable course and outcome of a disease and the prospects for a pt's recovery

Front 23

reverse chronological order

Back 23

arranging documents with the most recent document on top or in the front

Front 24

SOAP format

Back 24

process of arranging notes: subjective data, objective data, assessment, and plan

Front 25

subjective symptoms

Back 25

a symptom that is felt by the pt but is not observable by an examiner

Front 26

symptom

Back 26

any change in the body or its functioning that indicates the presence of disease

Front 27

BP

Back 27

blood pressure

Front 28

hour of sleep

Back 28

hs

Front 29

medication

Back 29

med, meds

Front 30

negative

Back 30

neg

Front 31

no known drug allerigies

Back 31

NKDA

Front 32

complaint of

Back 32

c/o

Front 33

without

Back 33

w/o, -

s

Front 34

with

Back 34

w/, -

c

Front 35

over the counter

Back 35

OTC

Front 36

after meals

Back 36

pc

Front 37

eye, ear, nose, throat

Back 37

EENT

Front 38

chief complaint

Back 38

cc

Front 39

dry and intact

Back 39

D&I

Front 40

Iron

Back 40

Fe

Front 41

abdomen

Back 41

abd

Front 42

date of birth

Back 42

DOB

Front 43

normal saline

Back 43

NS

Front 44

breast self exam

Back 44

BSE

Front 45

amount

Back 45

amt

Front 46

before meals

Back 46

ac

Front 47

aspirin

Back 47

ASA

Front 48

appointment

Back 48

appt

Front 49

two times a day

Back 49

bid

Front 50

discharge

Back 50

disch

Front 51

discontinue

Back 51

D/C

Front 52

prescription

Back 52

Rx

Front 53

pathology

Back 53

path

Front 54

now

Back 54

STAT

Front 55

three times a day

Back 55

tid

Front 56

by mouth

Back 56

PO

Front 57

patient

Back 57

pt

Front 58

obstetrics

Back 58

OB

Front 59

myocardial infarction

Back 59

MI

Front 60

ouce

Back 60

oz

Front 61

gastrointestinal

Back 61

GI

Front 62

upper respiratory infection

Back 62

URI

Front 63

complete blood count

Back 63

CBC

Front 64

benign prostatic hypertrophy

Back 64

BPH

Front 65

operating room

Back 65

OR

Front 66

nausea and vomitting

Back 66

N/V

Front 67

every hour

Back 67

qh

Front 68

verbal order

Back 68

VO

Front 69

left/right lower/upper quadrant

Back 69

LLQ/RUQ

Front 70

white blood count

Back 70

WBC

Front 71

shortness of breath

Back 71

SOB

Front 72

height, weight, history

Back 72

ht, wt, Hx

Front 73

temp, pulse, resp

Back 73

TPR

Front 74

vital signs

Back 74

VS

Front 75

after

Back 75

-

p

Front 76

urinary tract infection

Back 76

UTI

Front 77

urinalysis

Back 77

UA

Front 78

congestive heart failure

Back 78

CHF

Front 79

pelvic inflammatory disease

Back 79

PID

Front 80

sexually transmitted disease

Back 80

STD

Front 81

cerebral vascular accident

Back 81

CVA

Front 82

culture and sensitivity

Back 82

C&S

Front 83

biopsy

Back 83

Bx

Front 84

measles, mumps, rubella

Back 84

MMR

Front 85

expected date of delivery

Back 85

EDD

Front 86

last menstrual period

Back 86

LMP

Front 87

office visit

Back 87

OV

Front 88

low back pain

Back 88

LBP

Front 89

intravenous

Back 89

IV

Front 90

near visual acuity

Back 90

NVA

Front 91

cancer

Back 91

CA

Front 92

hemoglobin

Back 92

Hgb

Front 93

coronary artery disease

Back 93

CAD

Front 94

physical exam

Back 94

PE/Px

Front 95

subcutaneous

Back 95

subcut

Front 96

treatment

Back 96

Tx