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65 Cards in this Set
- Front
- Back
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Fl oz
|
fluid ounce
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Gr
|
grain
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Gt
|
drop
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Gtt
|
drops
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Dr
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Dram(1/8 oz)
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Oz
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Ounce
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Lb, #
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pound
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Qt
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quart
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WDWN
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well developed and well nourished
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Y/o or YO
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year old
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#
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Number(before)
Pounds(after) |
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C
F |
Celsius
Fahrenheit |
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Tx
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Treatment or Traction
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VS
|
vital signs
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T
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temperature
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P
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pulse
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R
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respiration
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BP
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blood pressure
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Ht
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height
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Wt
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weight
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BRP
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bathroom privileges
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CP
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chest pain
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ETOH
|
ethyl alcohol
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Pt
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patient
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RRR
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regular rate and respiration
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SOB
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shortness of breath
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TR
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treatment
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PACU
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postanesthetic care unit
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PAR
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postanestetic recovery
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post
pre op |
postoperative
preoperative |
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RTC
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return to clinic
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RTO
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return to office
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CCU
|
coronary(cardiac) care unit
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ECU
|
emergency carre unit
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ER
|
emergency room
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ICU
|
intenive catre unit
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OP
|
outpatient
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OR
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operating room
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Error-Prone Abbreviations
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Qod
SC,SubQ,SQ Hs DC or D/C Qd OD, OS, OU AD, AS, AU |
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sonography
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diagnostic ultrasound. used to examine abdomen, reproductive organs, thryroid glad, CardioVasc system
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MRI
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used to examine soft tissues, joints, brain,spinal cord
can image structure and fuction |
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MRA
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Magnetic resonance angiography
measures blood flow |
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Radionuclide organ imagine
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used in determining size, shape, and function of organs
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SPECT
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single photo emission computed tomography
used like PET but less sensitive |
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PET
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positionemission tomography.
radioactive isotopes decay detected by scanner |
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CAT
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generates cross-sectional views and 3D images of organs
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3 common diagnostic tests
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complete blood count
urinalysis metabolic panel |
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What should be included in a hospital report?
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History and Physical
Physicians Orders Nurse's notes Physicians progress Consultation Report Operative Report Anethesiologist Report Informed Consent Ancillary report Discharge Summary |
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SOAP
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Subjective(from pt)
Objective Assessment Plan |
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HEENT
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head ears eyes nose and throat
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PERRLA
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pupils equal round and reactive to light and accomodation
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NAD
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no acute distress
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WNL
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within normal limits
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SH
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social history
recreational interest, hobbies use of tobacco, alcohol, drugs |
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OH
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occupational history
work habits |
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ROS
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review of systems
complete review of functions of the body |
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UCHD
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usual childhood diseases
(History) |
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NKA
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no known allergies
(History) |
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NKDA
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no known drug allergies
(History) |
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FH
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family history
(History) immediate family members(mother, father siblings) |
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PI/HPI
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present illness/history of present illness
duration, severity, details of complaint, Sx |
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Sx
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Symptoms
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PH/PMH
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past history/past medical history
surgeries, injuries, medications, allergies |
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Hx
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document of subjective inco
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CC
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chief complaint, usually brief
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