Documentation Flashcards
1
Q
Recording skills
A
Charting , recording, documentation
2
Q
Who has access to pts medical information?
A
Government agencies : Medicare/Medicaid
Insurance agencies
Accreditation teams
3
Q
AMA
A
Against medical advice
4
Q
DC
A
Discharge or discontinue
5
Q
DNR
A
Do not resuscitate
6
Q
H&P
A
History & physical
7
Q
HPI
A
History of present illness
8
Q
H/O
A
History of
9
Q
NKDA
A
No known drug allergies
10
Q
PCP
A
Primary care physicians
11
Q
A&O
A
Alert and oriented
12
Q
WNL
A
Within normal limits
13
Q
RF
A
Risk factors
14
Q
Sx
A
Symptoms
15
Q
Dx
A
Diagnosis
