Nursing Documentation Flashcards
(111 cards)
1
Q
AAA
A
Abdominal Aortic Aneurysm
2
Q
Abd
A
Abdomen
3
Q
Ac
A
Before meals
4
Q
ACLS
A
Advanced Cardiac Life Support
5
Q
AD (2 answers)
A
Admitting diagnosis or Advance Directives
6
Q
A&D
A
Admission and Discharge
7
Q
Ad lib
A
As desired
8
Q
ADL
A
Activities of daily living
9
Q
Adm.
A
Administration
10
Q
AKA (2 answers)
A
Above-the-knee amputation or Alcoholic Ketoacidosis
11
Q
ALL
A
Acute Lymphocytic Leukemia
12
Q
Amb
A
Ambulation
13
Q
AP
A
Appendectomy
14
Q
A.P.
A
Anterior/Posterior
15
Q
AV
A
Atrioventricular
16
Q
Bid
A
Twice daily
17
Q
BKA
A
Below-the-knee amputation
18
Q
BLS
A
Basic Life Support
19
Q
BM
A
Bowel Movement
20
Q
BP
A
Blood Pressure
21
Q
BPH
A
Benign Prostatic Hyperplasia
22
Q
BUN
A
Blood Urea Nitrogen
23
Q
BX
A
Biopsy
24
Q
CABG
A
Coronary Artery Bypass Graft
25
CAD
Coronary Artery Disease
26
CBC
Complete Blood Count
27
CCU
Cardiac Care Unit
28
CF
Cystic Fibrosis
29
CHF
Congestive Heart Failure
30
CKD
Chronic Kidney Disease
31
C/O
Complaining of
32
COPD
Chronic obstructive pulmonary disease
33
CPR
cardiopulmonary resuscitation
34
C&S
Culture and Sensitivity
35
CVA
Cerebrovascular Accident (Stroke)
36
CVC
Central Venous Catheter
37
D/C (2 answers)
Discontinue or discharge
38
D&C
Dilatation and curettage
39
DI
Diabetes Insipidus
40
DIC
Disseminated Intravascular Coagulation
41
DKA
Diabetic Ketoacidosis
42
DM
Diabetes Mellitus
43
DVT
Deep Vein Thrombosis
44
DX
Diagnosis
45
ECG or EKG
electrocardiogram
46
ED
Emergency Department
47
EENT
Eyes, Ears, Nose, and Throat
48
ETT
Endotracheal Tube
49
FBS
Fasting Blood Sugar
50
Fx
Fracture
51
GI
Gastrointestinal
52
Gtt or G.T.T.
Glucose Tolerance Test
53
HOB
Head of Bed
54
HR
Heart Rate
55
HS
Bedtime
56
Hx
History
57
ICU
Intensive Care Unit
58
I&O
Intake and Output
59
LES
Lower Esophageal Sphincter
60
LMP
Last Menstrual Period
61
LOC
Level of Consciousness
62
LP
Lumbar Puncture
63
LPN
Licensed practical nurse
64
LVN
Licensed vocational nurse
65
MAP
Mean Arterial Pressure
66
MRI
Magnetic Resonance Imaging
67
MVA
Motor Vehicle Accident
68
NGT
Nasogastric Tube
69
NKA
No known allergies
70
NPO
Nothing by mouth
71
O2
Oxygen
72
OA
Osteoarthritis
73
OB
Obstetrics
74
OOB
Out of bed
75
OR
Operating room
76
Ortho
orthopedics
77
OT
occupational therapist/therapy
78
Pc
After meals
79
PFT
Pulmonary Function Test
80
PLT
Platelets
81
PRBC
Packed Red Blood Cells
82
Pre-op
Before surgery
83
Pm or PRN
As needed
84
PT
Physical therapist or physical therapy
85
PTCA
Percutaneous Transluminal Coronary Angioplasty
86
PVC
Premature Ventricular Contraction
87
RA
Rheumatoid Arthritis
88
RBC
Red Blood Cells
89
RN
Registered Nurse
90
ROM
Range of Motion
91
RT
Respiratory Therapist
92
SBAR
Situation, background, assessment, and recommendation
93
SIADH
Syndrome of Inappropriate Antidiuretic Hormone Secretion
94
SLE
Systemic Lupus Erythematosus
95
SOB
Shortness of breath
96
SSE or S.S.E
Soap Suds enema
97
Stat
At Once, immediately
98
STD
Sexually transmitted disease
99
TB
Tuberculosis
100
TIA
Transient Ischemic Attack
101
Tid
Three times daily
102
TPN
Total Parenteral Nutrition
103
T&S
Type and Screen
104
TURP
Transurethral Resection of the prostate
105
UA
Urinalysis
106
UAP
Unlicensed assistive personnel
107
US
Ultrasound
108
UTI
Urinary Tract Infection
109
VS
Vital Signs
110
WBC
White Blood Count
111
WNL
Within normal limits
