Legal & Ethical
Medical Records
MISC.
Injections
Abbreviations
100

Open threat of bodily harm against another person

Assault

100

Extending arm for phlebotomy and removing clothing for medical procedure or exam

Implied consent

100

CPT 

Current Procedural Terminology (5 digit code)

100

Insert needle at this angle for IM injection

90 degrees

100

Medication is to be given twice a day

BID

200

An action that causes bodily harm

Battery

200

Must have patient's signature to perform procedure

Written Consent

200

ICD

International Classification of Diseases

200

Insert needle at this angle for subcutaneous injections

45 degrees

200

Medication to be given at bedtime

HS (hours sleep)

300

Failure to do something that a reasonable prudent individual would do under similar circumstances 

Negligence

300

Inform patient of risk, possible outcomes, alternative therapies

Informed consent

300

Ishihara Test

Test for color blindness (red & green)

300

Preferred IM injection site for infants

Vastus Lateralis

300

Give the medication immediately

STAT

400

Negligent delivery of professional services

Malpractice

400

Health Insurance Portability & Accountability Act

HIPAA

400

The absence of bacteria, viruses, and other organisms

Asepsis

400

These account for over 7000 deaths in hospitals yearly

Medication Errors

400

Latin phrase meaning “as necessary”

PRN (“Pro Re Nata” )

500
A civil wrong committed against a person or property

Tort

500

The most important step in ensuring pt safety

Proper patient identification 

500

PASS=sequence of operating fire extinguisher

PULL the pin, AIM at base fire, SQUEEZE handle, SWEEP back and forth base of fire

500

6 rights of medication administration

Right Person, Right Medication, Right Dose, Right Time, Right Route, Right Reason, and Right Documentation  

500

Solu-Medrol 100 mg is ordered. When reconstituted, each 2 mL of the medication has 125 mg. How many mL will you administer to the patient if you have a 3 mL syringe?

1.6 mL

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