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Corpsman A-School > BN3 > Flashcards

BN3 Flashcards

1
Q

Assessment

A

-Diagnosis based on the data gathered from the subjective and objective of the patient

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2
Q

Objective

A

-Data which is measured and observed from the patient

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3
Q

Pertinent

A

-Relevant

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4
Q

Plan

A

-Care and treatment that the provider will be using to resolve the patients problem

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5
Q

Subjective

A

-Data obtained from verbalization’s from the patient

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6
Q

abd

A

-Abdominal

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7
Q

ABG

A

-Arterial blood gas

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8
Q

a.c.

A

-Before meals

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9
Q

ACLS

A

-Advanced cardiac life support

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10
Q

ADL

A

-Activities of daily living

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11
Q

ad lib

A

-As desired

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12
Q

am

A

-Morning

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13
Q

AMA

A

-Against medical advice

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14
Q

AMI

A

-Acute myocardial infarction (heart attack)

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15
Q

Amp

A

-Ampoule

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16
Q

amt

A

-Amount

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17
Q

A&Ox3

A

-Alert and oriented to person, place and time

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18
Q

ASA

A

-Acetylsalicylic acid or asprin

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19
Q

ASAP

A

-As soon as possible

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20
Q

bid

A

-Twice a day

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21
Q

bil, bilateral

A

-Both sides

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22
Q

BLS

A

-Basic life support

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23
Q

BM

A

-Bowel movement

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24
Q

B/P

A

-Blood pressure

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25
Q

BS

A

-Breath sounds or bowel souds

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26
Q

BSI

A

-Body substance isolation

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27
Q

BVM

A

-Bag valve mask

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28
Q

/c

A

-With

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29
Q

cap(s)

A

-Capsule(s)

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30
Q

c-spine

A

-Cervical spine

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31
Q

CBC

A

-Complete blood count

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32
Q

C/C

A

-Chief complaint

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33
Q

CHF

A

-Congestive heart failure

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34
Q

CNS

A

-Central Nervous system

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35
Q

c/o

A

-Complains of

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36
Q

COPD

A

-Chronic obstructive pulmonary disease

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37
Q

CPR

A

-Cardiopulmonary resuscitation

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38
Q

CSF

A

-Cerebrospinal fluid

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39
Q

CVA

A

-Cerebrovascualr accident (stroke)

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40
Q

CXR

A

-Chest X-Ray

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41
Q

Daily

A

-Once a day

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42
Q

DC

A

-Discontinue

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43
Q

dil.

A

-Dilute

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44
Q

DNR

A

-Do not resusitate

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45
Q

DOA

A

-Dead on arrival

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46
Q

DOB

A

-Date of birth

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47
Q

D5W

A

-5% dextrose in water

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48
Q

DX

A

-Diagnosis

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49
Q

ECG or EKG

A

-Electrocardiogram

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50
Q

ET

A

-Endotracheal

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51
Q

ETA

A

-Estimated time of arrival

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52
Q

ETOH

A

-Ethyl alcohol

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53
Q

Elix.

A

-Elixer

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54
Q

FBOA

A

-Foreign body obstructed airway

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55
Q

fl, fld

A

-Fluid

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56
Q

FX

A

-Fracture

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57
Q

g

A

-Gram

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58
Q

GI

A

-Gastrointestinal

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59
Q

gr

A

-Grain

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60
Q

gtt, gtts

A

-Drop, drops

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61
Q

h, hr

A

-Hour

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62
Q

HEENT

A

Head, eyes, ears, nose, throat

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63
Q

HDL

A

-High density lipoprotein

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64
Q

HIV

A

-Human immunodeficiency virus

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65
Q

HR

A

-Heart rate

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66
Q

HRR

A

-Heart rate regular

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67
Q

hs

A

-Hour of sleep, bedtime

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68
Q

ht

A

-Height

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69
Q

HTN

A

-Hypertension

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70
Q

HX

A

-History

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71
Q

I&D

A

-Incision and drainage

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72
Q

ID

A

-Intradermal

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73
Q

IM

A

-Intramuscular

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74
Q

INH

A

-Isoniazid (a drug prescribed for the treatment and prevention of tuberculosis)

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75
Q

inj.

A

-By injection

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76
Q

Irrig.

A

-Irrigation

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77
Q

IV

A

-Intravenous

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78
Q

IVP

A

-IV push

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79
Q

IVPB

A

-IV piggyback

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80
Q

kg

A

-Kilogram

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81
Q

kvo

A

-Keep vein open

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82
Q

L

A

-liter

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83
Q

lb, lbs

A

-Pound, pounds

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84
Q

LDL

A

-low density lipoprotien

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85
Q

LCTAB

A

-Lungs clear to auscultation bilaterally

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86
Q

LLQ, LLL

A

-Left Left lower quadrant (abdomen), left upper lobe (lung)

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87
Q

LMP

A

-Last menstrual period

88
Q

LOC

A

-Level of consciousness or loss of consciousness

89
Q

LOI

A

-Last oral intake

90
Q

LP

A

-Lumbar puncture (Spinal tap)

91
Q

LR

A

-Lactated ringer

92
Q

LUQ, LUL

A

-Left upper quadrant (abdomen), Left upper lobe (lung)

93
Q

meg

A

-Microgram

94
Q

mg

A

-Milligram

95
Q

mL

A

-Millimeter

96
Q

MVA

A

-Motor vehicle accident

97
Q

NIDDM

A

-noninsulin-dependent diabetes mellitus

98
Q

NVD

A

-Nausea, vomiting, diarreah

99
Q

neg

A

-Negetive

100
Q

NKA, NKDA

A

-No known allergies, no known drug allergies

101
Q

NPO

A

-Nothing by mouth

102
Q

NS, NaCI

A

-Normal saline

103
Q

NSR

A

-Normal sinus rhythm

104
Q

oz

A

-Ounce

105
Q

p

A

-After

106
Q

p.c.

A

-After meals

107
Q

PCN

A

-Penicillin

108
Q

per

A

-by or through

109
Q

PERRLA

A

-Pupils equal, round, reactive to light, and accomodation

110
Q

pm

A

-Between noon and midnight

111
Q

PO

A

-By mouth

112
Q

prn

A

-As needed, whenever necessary

113
Q

PT

A

-Patient or physical therapy

114
Q

PE

A

-Physical exam

115
Q

q

A

-Every

116
Q

qh

A

-Every hour

117
Q

q2h

A

-Every 2 hours, any number can be used

118
Q

qhs

A

-Every night at bedtime

119
Q

qid

A

-Four times a day

120
Q

qt

A

-Quart

121
Q

R, PR

A

-Rectal, per rectum

122
Q

RLQ, RLL

A

-Right lower quadrant (abdomen) right lower lobe (lung)

123
Q

RML

A

-Right middle lobe

124
Q

R/O

A

-Rule out

125
Q

ROM

A

-Range of motion

126
Q

RUQ, RUL

A

-Right upper quadrant (abdomen), Right upper lobe (lung)

127
Q

Rx

A

-Prescription

128
Q

/s

A

-Without

129
Q

S.L.

A

Sublingual

130
Q

SOB

A

-Shortness of breath

131
Q

subQ, Sub-Q

A

-Subcutaneous

132
Q

Stat

A

-Immediately

133
Q

SX

A

-Symptoms

134
Q

tab

A

-Tablet

135
Q

Tbsp

A

-Tablespoon

136
Q

tsp

A

-Teaspoon

137
Q

tid

A

-Three times a day

138
Q

Tx

A

-Treatment

139
Q

UA

A

-Urinalysis

140
Q

URI

A

-Upper respiratory infection

141
Q

V/S

A

-Vital signs

142
Q

VSS

A

-Vital signs stable

143
Q

WBC

A

-White blood cell

144
Q

WNL

A

-Within normal limits

145
Q

wt

A

-Weight

146
Q

Chronological

A

-Arranged according to the order of time

147
Q

Dental record

A

-A file of continuous dental care and treatment given to active duty, reserve members and their families

148
Q

Family Member Prefix (FMP)

A

-A number that designates sponsor ship

149
Q

Health record (HREC)

A

-A file of continuous care given to an active duty member and documents all outpatient care provided during a members career.

150
Q

Inpatient Record (IREC)

A

-A medical file which documents care provided to a patient assigned to a designated inpatient bed in a medical treatment facility

151
Q

Outpatient record (OREC)

A

-A file of continuous care which documents ambulatory treatment received by a person other than an active duty member (Retirees and family members)

152
Q

Military Treatment Facility (MTF)

A

-Location of military health records

153
Q

2100 Jacket

A

-Orange 0 series

154
Q

2110 Jacket

A

-Green 1 series

155
Q

2120 Jacket

A

-Yellow 2 series

156
Q

2130 Jacket

A

-Gray 3 series

157
Q

2140 Jacket

A

-Mustard/Tan 4 series

158
Q

2150 Jacket

A

-Blue 5 series

159
Q

2160 Jacket

A

-White 6 series

160
Q

2170 Jacket

A

-Brown 7 series

161
Q

2180 Jacket

A

-Pink 8 series

162
Q

2190 Jacket

A

-Red 9 series

163
Q

20 in family prefix

A

-Sponsor

164
Q

30 in family prefix

A

-Spouse

165
Q

31 in family prefix

A

-Second spouse

166
Q

01 in family prefix

A

-First child

167
Q

02 in family prefix

A

-Second child

168
Q

99 in family prefix

A

-Foreign military

169
Q

Part 1 in health record division

A

-Record of preventive medicine and occupational health

170
Q

Part 2 in health record division

A

-Chronological record of medical care and treatment

171
Q

Part 3 in health record division

A

-Physical qualifications physical profiles and exposure form

172
Q

Part 4 in health record division

A

-Record of ancillary studies and misc. forms.

173
Q

(Part 1) SF 601 or DD form 2766C

A

-Immunization record concerning hypersensitivities and allergies

174
Q

(Part 1) NAVMED 6000/2

A

-Chronological record of HIV testing

175
Q

(Part 1) DD Form 2215

A
  • Baseline audiogram.

- DD form 2216 may accompany if member is in hearing conservation program

176
Q

(Part 1) DD From 2766

A

-Adult preventive and chronic care flowsheet

177
Q

(Part 2) SF 600

A

-Chronological record of medical care

178
Q

(Part 2) SF 558

A
  • Emergency care and treatment

- Interfiled with SF 600’s in chronological order

179
Q

(Part 2) SF 502

A
  • Narrative summary

- Summary of treatment received during periods of hospitalization

180
Q

(Part 2) SF 507

A

-Medical record continuation

181
Q

(Part 2) SF 509

A
  • Progress notes

- Doctors

182
Q

(Part 2) SF 513

A
  • Consultation sheet
  • Used to refer a patient to a specialist for detailed exam and/or procedure
  • Filed immediately above SF 600 or SF 558 containing the last entry prior to the date of the SF513
183
Q

(Part 2) AF Form 348

A

-Line of duty determination

184
Q

(Part 2) AF Form 565

A

-Record of inpatient treatment

185
Q

(Part 2) AF Form 1480

A
  • Summary of care (Original)

- Health Enrollment assessment review (Original)

186
Q

(Part 3) NAVMED 6150/4

A
  • Abstract of service and medical history
  • Record of duty stations that is listed chronologically
  • Provides an abstract (diagnostic summary only) of medical history for each admission to the sick list
187
Q

(Part 3) DD Form 2005

A
  • Privacy act statement health care record
  • Used to inform patients of their privacy rights concerning their health record.
  • Don’t have to sign but rencouraged
188
Q

(Part 3) DD Form 2569

A

-Third party collection program

189
Q

(Part 3) OPNAV 5211/9

A
  • Record of disclosure

- Release of medical information as required by the privacy act of 1974

190
Q

(Part 3) DD Form 877

A
  • Request for medical/dental records or information

- Used to permanently transfer records to another facility

191
Q

(Part 3) DD Form 2795

A

-Pre-Deployment health assessment

192
Q

(Part 3) DD Form 2796

A
  • Post-Deployment health assessment (PDHA)

- Must be completed within 30 days of returning

193
Q

(Part 3) DD Form 2900

A
  • Post-Deployment health reassessment (PDHRA)

- Required after 6 months of returning

194
Q

(Part 3) SF 88 or DD Form 2808

A
  • Report of medical examination
  • Filled out upon entry and discharge or retirement of the military
  • Filed in conjunction with SF 93 or DD 2807-1
195
Q

(Part 3) SF 93 or Form 2807-1

A
  • Report of medical history
  • Record of history upon entry, discharge or when physical examination is required. -Filed in conjunction with SF 88 or DD 2808
196
Q

(Part 3) AF Form 422

A

-Physical profile serial support

197
Q

(Part 4) SF 545

A
  • Laboratory report display

- Sheet may be yellow

198
Q

(Part 4) SF 519

A
  • Radiological consultation requests/reports

- Sheet may be green

199
Q

(Part 4) SF 602

A

-Lab results

200
Q

Part 1 in forms in a dental record

A

-Contains dental X-Rays

201
Q

Part 2 in forms in a dental record

A

-Contains NAVMED 6600/3 (Dental health questionnaire)

202
Q

Part 3 in forms in a dental record

A
  • Contains EZ 603 (Dental Exam Form)

- Used for most dental exams

203
Q

Part 4 in forms in a dental record

A

-Contains EZ603A Form, SF 509 (Doctors progress notes)

204
Q

NAVMED 6550/14 in forms in the inpatient health record

A
  • Patient data base
  • Summary of patients health history to identify nursing care problems.
  • Patient completes section 1 nurse completes section 2 reviews section 1
205
Q

SF 502 in forms in the inpatient health record

A
  • Narrative summary
  • To be completed by a medical officer and the origional SF 502 is filed in out patient or military health record
  • A copy of SF 502 is filed in the inpatient treatment record
206
Q

SF 504 in forms in the inpatient health record

A
  • History part 1
  • Record a course of current hospitalization. Including signs and symptoms, duration of complaints and the circumstances of admission.
  • To be completed by a medical officer
207
Q

SF 505 in forms in the inpatient health record

A
  • History part 2 & 3
  • Records occupation, military history, lifetime injuries and illness, as well as drug sensitivities and allergies.
  • To be completed by a medical officer
208
Q

SF 506 in forms in the inpatient health record

A
  • Physical exam
  • Record of physical examinations including physical and mental characteristics.
  • To be completed by a medical officer
209
Q

SF 508 in forms in the inpatient health record

A
  • Doctors orders
  • Instructions written by physician directing the medical care and treatment of patient
  • Only nurses can accept verbal orders from doctor.
  • Some are carbon forms so meds can be sent to pharmacy
210
Q

SF 509 in forms in the inpatient health record

A
  • Progress notes
  • Used to record response to treatment
  • Other personnel may use this to record comments
211
Q

SF 510 in forms in the inpatient health record

A
  • Nursing notes

- Observations, patient progress, treatments, and some meds are recorded on this form by nurses and corpsman.

212
Q

NAVMED 6550/12 in forms in the inpatient health record

A
  • Patient profile/ Air Force inpatient flow chart
  • Used to standardize treatment and provide a ready reference for care given to a patient.
  • Not apart of permanent record.
213
Q

SF 511 in forms in the inpatient health record

A

-Vital signs record

214
Q

NAVMED 6550/8 in forms in the inpatient health record

A
  • Medication administration record
  • Transcribed form doctors orders
  • SF 508 to this form
215
Q

DD 792 in forms in the inpatient health record

A

-Twenty four hour intake and output worksheet

Corpsman A-School (16 decks)

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