Abbreviation
Shortened form of word/phrase
Anterior (ventral)
At/towards front of the body
Medical record
Chart/clinical record
Legal account of person’s condition and response to treatment/care
Communication
Exchange if information- correctly interpreted by receiver
Distal
Farthest from the center/point of attachment
Dorsal/Posterior
At/toward the back of body
Electronic Health Record (EHR)
Elect. Medical record-EMR
Electronic version of person’s medical record
End-of-shift report
Report nurse gives to the on-coming shift durning shift change
Kardex
Type of card file that summarizes information found in med record
(drugs, treatment, diagnoses, routine care measures, equipment, and special needs)
Lateral
Away from midline or at side of body
Medial
Near the middle/mid-line of body
Prefix
Word/element before the root word (changes meaning)
Progress note
Describes care given and person’s response/progress
Proximal
Nearest to center/point of attachment
Recording
Written account of care/observations - charting, documentation
Reporting
Oral account of care/observations
Root
Word/element containing basic meaning of word
Suffix
Word/element placed after root (changes meaning)
Word element
A part of a word
ADL (abbreviation)
Activities of Daily Living
EHR (abbreviation)
Electronic Health Record
EMR (abbreviation)
Electronic Medical Record
EPHI or ePHI (abbreviation)
Electronic Protected Health Information
PHI (abbreviation)
Protected Health Information
