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Flashcards in BN3 Deck (215):
1

Assessment

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

2

Objective

-Data which is measured and observed from the patient

3

Pertinent

-Relevant

4

Plan

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

5

Subjective

-Data obtained from verbalization's from the patient

6

abd

-Abdominal

7

ABG

-Arterial blood gas

8

a.c.

-Before meals

9

ACLS

-Advanced cardiac life support

10

ADL

-Activities of daily living

11

ad lib

-As desired

12

am

-Morning

13

AMA

-Against medical advice

14

AMI

-Acute myocardial infarction (heart attack)

15

Amp

-Ampoule

16

amt

-Amount

17

A&Ox3

-Alert and oriented to person, place and time

18

ASA

-Acetylsalicylic acid or asprin

19

ASAP

-As soon as possible

20

bid

-Twice a day

21

bil, bilateral

-Both sides

22

BLS

-Basic life support

23

BM

-Bowel movement

24

B/P

-Blood pressure

25

BS

-Breath sounds or bowel souds

26

BSI

-Body substance isolation

27

BVM

-Bag valve mask

28

/c

-With

29

cap(s)

-Capsule(s)

30

c-spine

-Cervical spine

31

CBC

-Complete blood count

32

C/C

-Chief complaint

33

CHF

-Congestive heart failure

34

CNS

-Central Nervous system

35

c/o

-Complains of

36

COPD

-Chronic obstructive pulmonary disease

37

CPR

-Cardiopulmonary resuscitation

38

CSF

-Cerebrospinal fluid

39

CVA

-Cerebrovascualr accident (stroke)

40

CXR

-Chest X-Ray

41

Daily

-Once a day

42

DC

-Discontinue

43

dil.

-Dilute

44

DNR

-Do not resusitate

45

DOA

-Dead on arrival

46

DOB

-Date of birth

47

D5W

-5% dextrose in water

48

DX

-Diagnosis

49

ECG or EKG

-Electrocardiogram

50

ET

-Endotracheal

51

ETA

-Estimated time of arrival

52

ETOH

-Ethyl alcohol

53

Elix.

-Elixer

54

FBOA

-Foreign body obstructed airway

55

fl, fld

-Fluid

56

FX

-Fracture

57

g

-Gram

58

GI

-Gastrointestinal

59

gr

-Grain

60

gtt, gtts

-Drop, drops

61

h, hr

-Hour

62

HEENT

Head, eyes, ears, nose, throat

63

HDL

-High density lipoprotein

64

HIV

-Human immunodeficiency virus

65

HR

-Heart rate

66

HRR

-Heart rate regular

67

hs

-Hour of sleep, bedtime

68

ht

-Height

69

HTN

-Hypertension

70

HX

-History

71

I&D

-Incision and drainage

72

ID

-Intradermal

73

IM

-Intramuscular

74

INH

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

75

inj.

-By injection

76

Irrig.

-Irrigation

77

IV

-Intravenous

78

IVP

-IV push

79

IVPB

-IV piggyback

80

kg

-Kilogram

81

kvo

-Keep vein open

82

L

-liter

83

lb, lbs

-Pound, pounds

84

LDL

-low density lipoprotien

85

LCTAB

-Lungs clear to auscultation bilaterally

86

LLQ, LLL

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

87

LMP

-Last menstrual period

88

LOC

-Level of consciousness or loss of consciousness

89

LOI

-Last oral intake

90

LP

-Lumbar puncture (Spinal tap)

91

LR

-Lactated ringer

92

LUQ, LUL

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

93

meg

-Microgram

94

mg

-Milligram

95

mL

-Millimeter

96

MVA

-Motor vehicle accident

97

NIDDM

-noninsulin-dependent diabetes mellitus

98

NVD

-Nausea, vomiting, diarreah

99

neg

-Negetive

100

NKA, NKDA

-No known allergies, no known drug allergies

101

NPO

-Nothing by mouth

102

NS, NaCI

-Normal saline

103

NSR

-Normal sinus rhythm

104

oz

-Ounce

105

p

-After

106

p.c.

-After meals

107

PCN

-Penicillin

108

per

-by or through

109

PERRLA

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

110

pm

-Between noon and midnight

111

PO

-By mouth

112

prn

-As needed, whenever necessary

113

PT

-Patient or physical therapy

114

PE

-Physical exam

115

q

-Every

116

qh

-Every hour

117

q2h

-Every 2 hours, any number can be used

118

qhs

-Every night at bedtime

119

qid

-Four times a day

120

qt

-Quart

121

R, PR

-Rectal, per rectum

122

RLQ, RLL

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

123

RML

-Right middle lobe

124

R/O

-Rule out

125

ROM

-Range of motion

126

RUQ, RUL

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

127

Rx

-Prescription

128

/s

-Without

129

S.L.

Sublingual

130

SOB

-Shortness of breath

131

subQ, Sub-Q

-Subcutaneous

132

Stat

-Immediately

133

SX

-Symptoms

134

tab

-Tablet

135

Tbsp

-Tablespoon

136

tsp

-Teaspoon

137

tid

-Three times a day

138

Tx

-Treatment

139

UA

-Urinalysis

140

URI

-Upper respiratory infection

141

V/S

-Vital signs

142

VSS

-Vital signs stable

143

WBC

-White blood cell

144

WNL

-Within normal limits

145

wt

-Weight

146

Chronological

-Arranged according to the order of time

147

Dental record

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

148

Family Member Prefix (FMP)

-A number that designates sponsor ship

149

Health record (HREC)

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

150

Inpatient Record (IREC)

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

151

Outpatient record (OREC)

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

152

Military Treatment Facility (MTF)

-Location of military health records

153

2100 Jacket

-Orange 0 series

154

2110 Jacket

-Green 1 series

155

2120 Jacket

-Yellow 2 series

156

2130 Jacket

-Gray 3 series

157

2140 Jacket

-Mustard/Tan 4 series

158

2150 Jacket

-Blue 5 series

159

2160 Jacket

-White 6 series

160

2170 Jacket

-Brown 7 series

161

2180 Jacket

-Pink 8 series

162

2190 Jacket

-Red 9 series

163

20 in family prefix

-Sponsor

164

30 in family prefix

-Spouse

165

31 in family prefix

-Second spouse

166

01 in family prefix

-First child

167

02 in family prefix

-Second child

168

99 in family prefix

-Foreign military

169

Part 1 in health record division

-Record of preventive medicine and occupational health

170

Part 2 in health record division

-Chronological record of medical care and treatment

171

Part 3 in health record division

-Physical qualifications physical profiles and exposure form

172

Part 4 in health record division

-Record of ancillary studies and misc. forms.

173

(Part 1) SF 601 or DD form 2766C

-Immunization record concerning hypersensitivities and allergies

174

(Part 1) NAVMED 6000/2

-Chronological record of HIV testing

175

(Part 1) DD Form 2215

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

176

(Part 1) DD From 2766

-Adult preventive and chronic care flowsheet

177

(Part 2) SF 600

-Chronological record of medical care

178

(Part 2) SF 558

-Emergency care and treatment
-Interfiled with SF 600's in chronological order

179

(Part 2) SF 502

-Narrative summary
-Summary of treatment received during periods of hospitalization

180

(Part 2) SF 507

-Medical record continuation

181

(Part 2) SF 509

-Progress notes
-Doctors

182

(Part 2) SF 513

-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

(Part 2) AF Form 348

-Line of duty determination

184

(Part 2) AF Form 565

-Record of inpatient treatment

185

(Part 2) AF Form 1480

-Summary of care (Original)
-Health Enrollment assessment review (Original)

186

(Part 3) NAVMED 6150/4

-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

(Part 3) DD Form 2005

-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

(Part 3) DD Form 2569

-Third party collection program

189

(Part 3) OPNAV 5211/9

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

190

(Part 3) DD Form 877

-Request for medical/dental records or information
-Used to permanently transfer records to another facility

191

(Part 3) DD Form 2795

-Pre-Deployment health assessment

192

(Part 3) DD Form 2796

-Post-Deployment health assessment (PDHA)
-Must be completed within 30 days of returning

193

(Part 3) DD Form 2900

-Post-Deployment health reassessment (PDHRA)
-Required after 6 months of returning

194

(Part 3) SF 88 or DD Form 2808

-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

(Part 3) SF 93 or Form 2807-1

-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

(Part 3) AF Form 422

-Physical profile serial support

197

(Part 4) SF 545

-Laboratory report display
-Sheet may be yellow

198

(Part 4) SF 519

-Radiological consultation requests/reports
-Sheet may be green

199

(Part 4) SF 602

-Lab results

200

Part 1 in forms in a dental record

-Contains dental X-Rays

201

Part 2 in forms in a dental record

-Contains NAVMED 6600/3 (Dental health questionnaire)

202

Part 3 in forms in a dental record

-Contains EZ 603 (Dental Exam Form)
-Used for most dental exams

203

Part 4 in forms in a dental record

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

204

NAVMED 6550/14 in forms in the inpatient health record

-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

SF 502 in forms in the inpatient health record

-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

SF 504 in forms in the inpatient health record

-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

SF 505 in forms in the inpatient health record

-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

SF 506 in forms in the inpatient health record

-Physical exam
-Record of physical examinations including physical and mental characteristics.
-To be completed by a medical officer

209

SF 508 in forms in the inpatient health record

-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

SF 509 in forms in the inpatient health record

-Progress notes
-Used to record response to treatment
-Other personnel may use this to record comments

211

SF 510 in forms in the inpatient health record

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

212

NAVMED 6550/12 in forms in the inpatient health record

-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

SF 511 in forms in the inpatient health record

-Vital signs record

214

NAVMED 6550/8 in forms in the inpatient health record

-Medication administration record
-Transcribed form doctors orders
-SF 508 to this form

215

DD 792 in forms in the inpatient health record

-Twenty four hour intake and output worksheet