BN3 Flashcards
(215 cards)
1
Q
Assessment
A
-Diagnosis based on the data gathered from the subjective and objective of the patient
2
Q
Objective
A
-Data which is measured and observed from the patient
3
Q
Pertinent
A
-Relevant
4
Q
Plan
A
-Care and treatment that the provider will be using to resolve the patients problem
5
Q
Subjective
A
-Data obtained from verbalization’s from the patient
6
Q
abd
A
-Abdominal
7
Q
ABG
A
-Arterial blood gas
8
Q
a.c.
A
-Before meals
9
Q
ACLS
A
-Advanced cardiac life support
10
Q
ADL
A
-Activities of daily living
11
Q
ad lib
A
-As desired
12
Q
am
A
-Morning
13
Q
AMA
A
-Against medical advice
14
Q
AMI
A
-Acute myocardial infarction (heart attack)
15
Q
Amp
A
-Ampoule
16
Q
amt
A
-Amount
17
Q
A&Ox3
A
-Alert and oriented to person, place and time
18
Q
ASA
A
-Acetylsalicylic acid or asprin
19
Q
ASAP
A
-As soon as possible
20
Q
bid
A
-Twice a day
21
Q
bil, bilateral
A
-Both sides
22
Q
BLS
A
-Basic life support
23
Q
BM
A
-Bowel movement
24
Q
B/P
A
-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
