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