Jane Dares Record Essay

1195 Words Aug 15th, 2015 5 Pages
Instructions
Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report. Abbreviation | Letters Represent | Context Definition or Application within the Patient’s Chart | Source Document | 1. ICD | International classification of diseases. | States the classification of coding use | Admission
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cc | Cubic centimeters | A unit of volume equal to one thousandth of a liter | History & Physical | 16. HEENT | Head, eyes, ears, nose, throat. | Is usually the initial part of a general physical exam, after vital signs. | History & Physical | 17. IV | Intravenous | The method by which medications will be administered into | History & Physical | 18. O2 | oxygen | Patient needs oxygen which is administered via gas | History & Physical | 19. EKG | Electrocardiogram/Electrocardiography | A record of the electrical activity of the heart | Transfer Form | 20. CBC | Complete blood count | A diagnostic test used to identify the level of all blood cell types in the quantity of blood | Transfer form | 21. ADL’s | Activities of daily living | Perform self-care activities e.g. feeding yourself or bathing. | Transfer form | 22. MSW | Medical social worker | Someone employed to provide social services to the patient | Social service screening | 23. PT | Physical therapy | The treatment of diseases, injury or deformity by physical methods e.gs .massage, exercise. | Physician orders & Progress notes | 24. HCL | Hydrochloride | A compound of a particular organic base with hydrochloric acid. | Physician order & Progress notes | 25. VO | Verbal or voice order | Are prescriptions and directions

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