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Exam 1: Chapter 2
Health Care Records
181
Nursing
Professional
08/02/2013
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Term
A
 Definition
assesment
Term
a
 Definition
before
Term
a.c.
 Definition
before meals
Term
AD
 Definition
right ear
Term
ad lib.
 Definition
as desired
Term
a.m.
 Definition
before noon
Term
amt
 Definition
amount
Term
aq
 Definition
water
Term
AS
 Definition
left ear
Term
AU
 Definition
both ears
Term
A&W
 Definition
alive and well
Term
 Definition
bilateral
Term
b.i.d.
 Definition
twice a day
Term
BP
 Definition
blood pressure
Term
BRP
 Definition
bathroom privileges
Term
C
 Definition
Celsius, centigrade
Term
c
 Definition
with
Term
cap
 Definition
capsule
Term
CAT
 Definition
computed axial tomography
Term
CBC
 Definition
complete blood count
Term
CC
 Definition
cheif complaint
Term
cc
 Definition
cubic centimeter
Term
CCU
 Definition
coronary (cardiac) care unit
Term
cm
 Definition
centimeter
Term
c/o
 Definition
complains of
Term
CP
 Definition
chest pain
Term
CT
 Definition
computed tomography
Term
cu mm or
 Definition
cubic millimeter
Term
d
 Definition
day
Term
DC or D/C
 Definition
discharge; discontinue
Term
dr
 Definition
dram
Term
Dx
 Definition
diagnosis
Term
ECU
 Definition
emergency care unit
Term
ER
 Definition
emergency room
Term
ETOH
 Definition
ethyl alcohol
Term
F
 Definition
Fahrenheit
Term
FH
 Definition
family history
Term
fl oz
 Definition
fluid ounce
Term
g or gm
 Definition
gram
Term
gr
 Definition
grain
Term
gt
 Definition
drop
Term
gtt
 Definition
drops
Term
h
 Definition
hour
Term
HEENT
 Definition
head, eyes, ears, nose, and throat
Term
H&P
 Definition
history and physical
Term
HPI
 Definition
history of present illness
Term
h.s.
 Definition
hour of sleep (bedtime)
Term
Ht
 Definition
height
Term
Hx
 Definition
history
Term
ICU
 Definition
intensive care unit
Term
ID
 Definition
intradermal
Term
IM
 Definition
intramuscular
Term
IMP
 Definition
impression
Term
IP
 Definition
inpatient
Term
IV
 Definition
intravenous
Term
JCAHO
 Definition
joint commission on accreditation of healthcare organizations
Term
kg
 Definition
kilogram
Term
L
 Definition
liter
Term
L (with a circle around it)
 Definition
left
Term
lb
 Definition
pound
Term
L&W
 Definition
living and well
Term
m (with a circle around it)
 Definition
murmur
Term
mg
 Definition
milligram
Term
mL or ml
 Definition
milliliter
Term
mm
 Definition
millimeter
Term
MRA
 Definition
magnetic resonance angiography
Term
MRI
 Definition
magnetic resonance imaging
Term
NAD
 Definition
no acute distress
Term
NKA
 Definition
no known allergies
Term
NKDA
 Definition
no known drug allergies
Term
noc.
 Definition
night
Term
NPO
 Definition
nothing by mouth
Term
O
 Definition
objective information
Term
OD
 Definition
right eye
Term
OH
 Definition
occupational history
Term
OP
 Definition
outpatient
Term
OR
 Definition
operating room
Term
OS
 Definition
left eye
Term
OU
 Definition
both eyes
Term
oz
 Definition
ounce
Term
P
 Definition
plan; pulse
Term
p
 Definition
after
Term
PACU
 Definition
postanesthetic care unit
Term
p.c.
 Definition
after meals
Term
PE
 Definition
physical examinaiton
Term
per
 Definition
by or through
Term
PERRLA
 Definition
pupils equal, round, and reactive to light and accommodation
Term
PH
 Definition
past history
Term
PI
 Definition
present illness
Term
p.m.
 Definition
after noon
Term
PMH
 Definition
past medical history
Term
p.o.
 Definition
by mouth
Term
post-op or postop
 Definition
postoperative (after surgery)
Term
PR
 Definition
through rectum
Term
pre-op or preop
 Definition
preoperative (before surgery)
Term
p.r.n.
 Definition
as needed
Term
pt
 Definition
patient
Term
PV
 Definition
through vagina
Term
Px
 Definition
physical
Term
q
 Definition
every
Term
q.d.
 Definition
every day
Term
qh
 Definition
every hour
Term
q2h
 Definition
every two hours
Term
q.i.d.
 Definition
four times a day
Term
q.o.d.
 Definition
every other day
Term
qt
 Definition
quart
Term
R
 Definition
respiration
Term
R (with a circle around it)
 Definition
right
Term
R/O
 Definition
rule out
Term
ROS
 Definition
review of systems
Term
RRR
 Definition
regular rate and rhythm
Term
RTC
 Definition
return to clinic
Term
RTO
 Definition
return to office
Term
Rx
 Definition
recipe; prescription
Term
S
 Definition
subjective information
Term
s
 Definition
without
Term
SC, SQ, or sub-Q
 Definition
subcutaneous
Term
SH
 Definition
social history
Term
Sig
 Definition
label; instruction to the patient
Term
SOB
 Definition
shortness of breath
Term
SR
 Definition
systems review
Term
ss
 Definition
one-half
Term
STAT
 Definition
immediately
Term
suppos
 Definition
suppository
Term
Sx
 Definition
symptom
Term
T
 Definition
temperature
Term
tab
 Definition
tablet
Term
t.i.d.
 Definition
three times a day
Term
Tr
 Definition
treatment
Term
Tx
 Definition
treatment; traction
Term
UA
 Definition
urinalysis
Term
UCHD
 Definition
usual childhood diseases
Term
US or U/S
 Definition
ultrasound (sonography)
Term
VS
 Definition
vital signs
Term
wa
 Definition
while awake
Term
WDWN
 Definition
well-developed and well-nourished
Term
wk
 Definition
week
Term
WNL
 Definition
within normal limits
Term
Wt
 Definition
weight
Term
x
 Definition
times or for
Term
x-ray
 Definition
radiology
Term
y/o or y.o.
 Definition
year old
Term
yr
 Definition
year
Term
i
 Definition
one
Term
ii
 Definition
two
Term
iii
 Definition
three
Term
iv
 Definition
four
Term
I, II, III, IV, V, VI, VII, VIII, IX, X
 Definition
1-10
Term
<
 Definition
less than
Term
>
 Definition
greater than
Term
#
 Definition
number; pound
Term
(up arrow)
 Definition
increased
Term
(down arrow)
 Definition
decreased
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 noncanerous
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 base on an evaluation of symptoms, signs, and test findings (results) (dia=through; gnosis=knowing)
Term
etiology
 Definition
study of the cause of a disease (etio=cause)
Term
exacerbation
 Definition
increase in the severity of a disease, with aggravation of symptoms (ex=out; acerbo=harsh)
Term
remission
 Definition
a period in which symptoms and signs stop or abate
Term
febrile
 Definition
relating to a fever (elevated temperature)
Term
idiopathic
 Definition
a condition occurring without a clearly identified cause (idio=one's own)
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 (e.g., "Prognosis: good")
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 (pro=before; phylassein=guard)
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 noticed 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 (e.g., menopausal syndrome)
Term
noncontributory
 Definition
not involved in bringing on the condition or result
Term
unremarkable
 Definition
common; not out of the ordinary or significant
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