Medical records
Everything you need to know about a patient's past issues, procedures, and medications.
History.
Which organization provides standard of care that focus on patient safety and quality care?
Joint Commissions, which also provides a "do not use" list of abbreviations.
Ultra-???
BONUS: What is an ultrasound?
Beyond.
ULTRASOUND: Using soundwaves to image an internal body structure. Beyond sound.
Crin/o
EXAMPLE: Endocrine
To secrete.
ENDOCRINE: To secret inside.
???-dipsia
BONUS: What is Polydipsia?
Thirst. POLYDIPSIA: Much thirst; very thirsty.
HIIPA consent for any procedures and surgeries.
Consents.
HOB
Head of bed.
EXAMPLE: HOB 30° (Head of Bed at 30° angle)
Trans-???
BONUS: What is a transsphenoidal?
Across.
TRANSSPHENOIDAL: Across or through the sphenoid bone.
Gonad/o
EXAMPLE: Gonadopathy.
Gonad, gamete-producing gland.
GONADOPATHY: The disease of the gonad.
???-edema
BONUS: What is myxedema?
Swelling. MYXEDEMA: Swelling in the face caused by advanced hypothyroidism.
The evaluation by a physician about the patient's current health status, beginning diagnoses, and plan of treatment. BONUS: What is the abbreviated word?
SOAP (Subjective, Objective, Assessment, Plan)
PE
Physical Examination.
EXAMPLE: PE; HR 80, lungs clear. (The physical examination of a patient's heart rate is 80 beats per minute, their lungs are healthy.) Sometimes, though, their lungs being "clear" could mean something else.
Supra- ???
BONUS: What is Suprarenal?
Above.
SUPRARENAL: Adrenal Glands; Above the kidney.
Isch/o
EXAMPLE: Ischemia
To hold back; Suppress.
ISCHEMIA: Suppressing the blood.
BONUS: What is hyponatremia?
Blood. HYPOATREMIA: Low blood sodium; less sodium in the circulating blood.
Describes the results ordered such as medical laboratory tests, x-rays, and other examinations completed.
Diagnostic Reports.
PTA
Prior to admission.
EXAMPLE: Pt. reports SOB for 2 days PTA. (Patient reports shortness of breath for 2 days prior to admission.)
Dia-???
BONUS: What is Diaphoresis?
Through, across.
DIAPHORESIS: Across sweat; An excessive amount of sweating through the skin.
Kali/o
EXAMPLE: Hypokalemia
Potassium.
HYPOKALEMIA: The condition of low blood potassium.
???-lytic
BONUS: What is thyrolytic?
Destroy. THYROLYTIC: Damage to the thyroid gland.
Evaluations from any physicians the patient has seen.
consultation reports.
SIG (unless it has to be lowercase; sig)
Directions of use; Give as follows; Let it be labeled.
EXAMPLE: sig component consists of; Rx (prescription) bid (2 times a day) PRN (as needed); Rx bid PRN.
Ex- ???
BONUS: What is the Exocrine Gland?
Out of, from. EXOCRINE GLAND: Releases secretions out through the duct and not through the blood.
Parathyr/o
EXAMPLE: Parathyrotropic.
Parathyroid.
PARATHYROTROPHIC: Nourishing the parathyroid gland.
???-oid.
BONUS: What is a steroid?
Resembling. STEROID: Resembling sterol or solid lipid.