DOCUMENTATION Flashcards
(55 cards)
1
Q
ABG
A
arterial blood gases
2
Q
AMA
A
against medical advice
3
Q
amb
A
Ambulation
4
Q
ABI
A
acquired brain injury
5
Q
ASA
A
aspirin
6
Q
ALS
A
amyotrophic lateral sclerosis
7
Q
BUN
A
blood urea nitrogen (blood test)
8
Q
CA
A
cancer / carcinoma
9
Q
c/o
A
complains of
10
Q
CAT
A
computerized axial tomography
11
Q
DNR
A
do not resuscitate
12
Q
CC, C/C
A
chief complaint
13
Q
DM
A
diabetes mellitus
14
Q
Dx
A
diagnosis
15
Q
CSF
A
cerebrospinal fluid
16
Q
DOE
A
dyspnea on exertion
17
Q
CMV
A
cytomegalovirus
18
Q
A:
A
assessment
19
Q
ac
A
before meals
20
Q
ad lib
A
at discretion
21
Q
D/C
A
discontinued or discharged
22
Q
FH
A
family history
23
Q
hs
A
at bed time
24
Q
Hx
A
history
25
GSW
gunshot wound
26
fx
fracture
27
h/o
history of
28
HOB
head of bed
29
IRDS
infant respiratory distress syndrome
30
KAFO
knee-ankle-foot orthosis
31
KUB
kidney-ureter-bladder
32
LOC
loss of consciousness
33
nn
nerve
34
LBBB
left bundle branch block
35
LBP
low back pain
36
noc
night, at night
37
O:
objective
38
od
once daily
39
ORIF
open reduction, internal fixation
40
NSR
normal sinus rhythm
41
P:
plan, intervention plan, plan of care
42
para
paraplegia
43
q
every
44
qid
four times a day
45
re:
regarding
46
PRE
progressive-resistive exercise
47
r/o, R/O
ruled out
48
TIS
transient ischemic attack
49
tid
three times daily
50
→
to progressing toward, approaching primary
51
w/c
wheelchair
52
~ or ≈
approximately
53
WNL
within normal limits
54
VD
venereal disease
55
SOB
shortness of breath
