Abbreviations
BID
twice (two times)per day
QD
once(one time) per day
TID
three times per day
Assessment & Auscultation
examining a situation so that it can be evaluated.
the act of listening to the internal sounds of the body with a stethoscope
sim' s position & Snellen chart
body position in which a person is lying on left side with the upper knee flexed and raised towards the chest.
chart used to assess visual acuity and check for myopia and hyperopia
fx
fracture
R/O
rule out
tx
treatment
Diagnosis & Fowler’s position
physician’s determination of an illness.
a body position in which a patient lies with the legs extended on an examining table or bed with head of bed elevated 45 degrees
SOAP notes & subjective
Subjective, Objective, Assessment, Plan for patient care.
descriptions based on feelings or opinions about a situation
NPO
nothing by mouth
ROM
range of motion
VS
Vital signs
Inspection & Objective
the visual examination of a body part.
descriptions based on facts about a situation
Supine position & symptoms
a body position in which a patient is lying flat on their back with the arms at each side.
a piece of subjective information about a disease or condition; is based on a person’s feelings or opinions
po
by mouth
Rx
medical prescription
T-
P-
R-
BP-
T- temperature
P-pulse
R- Respirations
BP- blood pressure
Plan & prognosis
provides directions and serves as a guide to delivering individualized, holistic care.
a projection of the likely course and outcome of a disease and the potential for recovery
Therapeutic & Trendelenburg
having a healing effect on the body.
a body position in which the patient lies on their back and the legs are raised above the head
px
pain
s/sn
signs/ symptoms
WNL
within normal limits
prone position & sign
a body position in which a patient lies on abdomen with arms and hands at each side, feet comfortably positioned, and head turned to side.
a piece of objective or factual information about a disease or a condition
Visual Acuity:
an assessment of visual clarity using a Snellen chart