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Health Care Records
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190
Health Care
10/23/2011
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Term
A
 Definition
assessment
Term
A&W
 Definition
alive and well
Term
CC
 Definition
chief complaint
Term
c/o
 Definition
complains of
Term
Dx
 Definition
diagnosis
Term
FH
 Definition
family history
Term
HEENT
 Definition
head, eyes, ears, nose, and throat
Term
H&P
 Definition
history and physical
Term
HPI, PI
 Definition
history of present illness, present illness
Term
Hx
 Definition
history
Term
IMP
 Definition
impression
Term
L&W
 Definition
living and well
Term
NAD
 Definition
no acute distress
Term
NKA
 Definition
no known allergies
Term
NKDA
 Definition
no known drug allergies
Term
O
 Definition
objective information
Term
OH
 Definition
occupational history
Term
P
 Definition
plan (recommendation, disposition)
Term
PE, Px
 Definition
physical examination
Term
PERRLA
 Definition
pupils equal, round, and reactive to light and accommodation
Term
PH, PMH
 Definition
past history, past medical history
Term
R/O
 Definition
rule out
Term
ROS
 Definition
review of systems
Term
SR
 Definition
systems review
Term
S
 Definition
subjective information
Term
SH
 Definition
social history
Term
Sx
 Definition
symptom
Term
UCHD
 Definition
usual childhood diseases
Term
WNL
 Definition
within normal limits
Term
SOAP
 Definition
subjective: patient describes
objective: observable info
assessment
plan
Term
ionizing
 Definition
a process that changes the electrical charge of atoms and has a possible effect on body cells
Term
radiography
 Definition
an imaging modality that uses x-rays (ionizing radiation) to produce images of the body's anatomy for the diagnosis of a condition or impairment
Term
radiograph
 Definition
the image created when a small amount of radiation is passed through the body to expose a sensitive film
Term
CT
 Definition
computed tomography
Term
CAT
 Definition
computed axial tomography
Term
CT or CAT
 Definition
a radiologic procedure that uses a machine, called a scanner, to examine a body site by taking a series of cross-sectional (tomographic) x-ray films in a full-circle rotation
Term
nuclear medicine imaging or radionuclide organ imaging
 Definition
uses an injected or ingested radioactive isotope that emits gamma rays. a gamma camera detects and produces an image of the distributed gamma rays in the body
Term
magnetic resonance imaging
 Definition
nonionizing imaging technique using magnetic fields and radiofrequency waves to visualize anatomic structures within the body
Term
MRI
 Definition
magnetic resonance imaging
Term
magnetic resonance angiography
 Definition
applies magnetic resonance technology in the study of blood flow
Term
MRA
 Definition
magnetic resonance angiography
Term
sonography or diagnostic ultrasound
 Definition
the use of high-frequency sound waves (ultrasound) to visualize body tissues
Term
U/S or US
 Definition
diagnostic ultrasound
Term
acute
 Definition
sharp; having intense, often severe symptoms and a short course
Term
chronic
 Definition
a condition that develops slowly and persists over a period of time
Term
benign
 Definition
mild or noncancerous
Term
malignant
 Definition
harmful or cancerous
Term
degeneration
 Definition
gradual deterioration of normal cells and body functions
Term
degenerative disease
 Definition
any disease in which deterioration of the structure or function of tissue occurs
Term
diagnosis
 Definition
determination of the presence of a disease based on an evaluation of symptoms, signs, and test findings
Term
etiology
 Definition
study of the cause of a disease
Term
exacerbation
 Definition
increase in the severity of a disease, with aggravation of symptoms
Term
remission
 Definition
a period in which symptoms and signs stop or abate
Term
febrile
 Definition
relating to a fever
Term
idiopathic
 Definition
a condition occuring without a clearly identified cause
Term
localized
 Definition
limited to a definite area or part
Term
systemic
 Definition
relating to the whole body rather than to only a part
Term
malaise
 Definition
a feeling of uneasiness or discomfort; often the first indication of illness
Term
marked
 Definition
significant
Term
morbidity
 Definition
sick; a diseased state
Term
mortality
 Definition
the state of being subject to death
Term
prognosis
 Definition
foreknowledge; prediction of the likely outcome of a disease based on the general health status of the patient along with knowledge of the usual course of the disease; often noted in one word
Term
progressive
 Definition
pertaining to the advance of a condition as the signs and symptoms increase in severity
Term
prophylaxis
 Definition
a process or measure that prevents disease
Term
recurrent
 Definition
to occur again; describes a return of symptoms and signs after a period of quiescence (rest or inactivity)
Term
sequela
 Definition
a disorder or condition usually resulting from a previous disease or injury
Term
sign
 Definition
a mark; objective evidence of disease that can be seen or verified by an examiner
Term
symptom
 Definition
subjective evidence of disease that is perceived by the patient and often noted in his or her own words
Term
syndrome
 Definition
a running together; combination of symptoms and signs that give a distinct clinical picture indicating a particular condition or disease
Term
noncontributory
 Definition
not involved in bringing on the condition or result
Term
unremarkable
 Definition
common; not out of the ordinary or significant
Term
CCU
 Definition
coronary (cardiac) care unit
Term
ECU
 Definition
emergency care unit
Term
ER
 Definition
emergency room
Term
ICU
 Definition
intensive care unit
Term
IP
 Definition
inpatient
Term
OP
 Definition
outpatient
Term
OR
 Definition
operating room
Term
PACU
 Definition
postanesthetic care unit
Term
PAR
 Definition
postanesthetic recovery
Term
post-op or postop
 Definition
postoperative (after surgery)
Term
pre-op or preop
 Definition
preoperative (before surgery)
Term
RTC
 Definition
return to clinic
Term
RTO
 Definition
return to office
Term
BRP
 Definition
bathroom privileges
Term
CP
 Definition
chest pain
Term
DC or D/C
 Definition
discharge, discontinue
Term
ETOH
 Definition
ethyl alcohol
Term
pt
 Definition
patient
Term
RRR
 Definition
regular rate and rhythm
Term
SOB
 Definition
shortness of breath
Term
Tr
 Definition
treatment
Term
Tx
 Definition
treatment or traction
Term
VS
 Definition
vital signs
Term
T
 Definition
temperature
Term
P
 Definition
pulse
Term
R
 Definition
respiration
Term
BP
 Definition
blood pressure
Term
Ht
 Definition
height
Term
Wt
 Definition
weight
Term
WDWN
 Definition
well-developed and well-nourished
Term
y/o or y.o.
 Definition
year old
Term
#
 Definition
number or pound
Term
C
 Definition
celsius
Term
F
 Definition
fahrenheit
Term
cc
 Definition
cubic centimeter
Term
cm
 Definition
centimeter
Term
g or gm
 Definition
gram
Term
kg
 Definition
kilogram
Term
1 cc = ? mL
 Definition
1cc = 1mL
Term
1 inch = ? cm
 Definition
1 inch = 2.54 cm
Term
1 kg = ? lbs
 Definition
1 kg = 2.2 lbs
Term
L
 Definition
liter
Term
mg
 Definition
milligram
Term
mL or ml
 Definition
milliliter
Term
mm
 Definition
millimeter
Term
cu mm or mm^3
 Definition
cubic millimeter
Term
fl oz
 Definition
fluid ounce
Term
gr
 Definition
grain
Term
gt
 Definition
drop
Term
gtt
 Definition
drops
Term
dr
 Definition
dram
Term
dr = ? oz
 Definition
dr = 1/8 ounce
Term
oz
 Definition
ounce
Term
lb or #
 Definition
pound
Term
1 lb = ? oz
 Definition
1 lb = 16 oz
Term
qt
 Definition
quart
Term
1 qt = ? ounces
 Definition
1 qt = 32 oz
Term
ID
 Definition
intradermal
Term
IM
 Definition
intramuscular
Term
IV
 Definition
intravenous
Term
SC, SQ, or sub-Q
 Definition
subcutaneous injection
Term
SL
 Definition
sublingual
Term
PV
 Definition
per vagina, vaginal
Term
PR
 Definition
per rectum, rectal
Term
What are the solid or semi-solid drug forms?
 Definition
tablet
capsule
suppository
Term
How are tablets or capsules administered?
 Definition
oral
sublingual
buccal
Term
How are suppositories administered?
 Definition
vaginal
rectal
Term
oral
 Definition
by mouth
Term
sublingual
 Definition
under the tongue
Term
buccal
 Definition
in the cheek
Term
vaginal
 Definition
inserted in the vagina
Term
rectal
 Definition
inserted in the rectum
Term
What are the liquid forms of drugs?
 Definition
fluid
parenteral
cream, lotion, ointment
Term
aerosol
 Definition
spray
Term
nebulizer
 Definition
device used to produce a fine spray or mist, often in a metered dose
Term
topical
 Definition
applied to the surface of the skin
Term
transdermal
 Definition
absorption of drug through unbroken skin
Term
implant
 Definition
a drug reservoir imbedded in the body to provide continual infusion of a medication (ex. insulin pump)
Term
a.c.
 Definition
before meals
Term
a.m.
 Definition
before noon
Term
b.i.d.
 Definition
twice a day
Term
d
 Definition
day
Term
h
 Definition
hour
Term
h.s.
 Definition
bedtime (spell this out!)
Term
noc.
 Definition
night
Term
p.c.
 Definition
after meals
Term
p.m.
Definition
after noon
Term
p.r.n.
 Definition
as needed
Term
q
 Definition
every
Term
q.d.
 Definition
every day (spell this out!)
Term
qh
 Definition
every hour
Term
q2h
 Definition
every 2 hours
Term
q.i.d.
 Definition
four times a day
Term
q.o.d.
 Definition
every other day (spell this out!)
Term
STAT
 Definition
immediately
Term
t.i.d.
 Definition
three times a day
Term
wk
 Definition
week
Term
yr
 Definition
year
Term
AD
 Definition
right ear
Term
ad lib.
 Definition
as desired
Term
amt
 Definition
amount
Term
aq
 Definition
water
Term
AS
 Definition
left ear
Term
AU
 Definition
both ears
Term
c
 Definition
with
Term
NPO
 Definition
nothing by mouth
Term
OD
 Definition
right eye
Term
OS
 Definition
left eye
Term
OU
 Definition
both eyes
Term
per
 Definition
by or through
Term
p.o.
 Definition
by mouth
Term
Rx
 Definition
recipe, prescription
Term
s
 Definition
without
Term
Sig
 Definition
label; instruction to the patient
Term
ss
 Definition
one-half
Term
wa
 Definition
while awake
Term
x
 Definition
times or for
Term
<
 Definition
less than
Term
>
 Definition
greater than