Patient Care
An 82-year-old patient recovering from a stroke requires assistance with bathing, dressing, and eating. During the assessment, the provider documents that the patient needs help performing these.
What is ADL?
A patient complains of headaches and blurred vision. Before notifying the provider, the medical assistant repeats this vital sign because the initial reading was 182/104.
What is BP?
A patient presents with polyuria, polydipsia, and an elevated fasting blood glucose of 168 mg/dL. The provider suspects this condition.
What is DM?
A patient with fatigue, fever, and easy bruising has blood drawn to evaluate red blood cells, white blood cells, hemoglobin, hematocrit, and platelets.
What is CBC?
The physician cites clinical guidelines published by this national organization representing physicians when discussing treatment recommendations.
What is AMA?
A Patient with chest pain is informed of the risks of leaving before test results return. They sign paperwork acknowledging the risks and leave anyway.
What is a.m.a?
A postoperative patient reports abdominal discomfort and states they have not had one since surgery three days ago.
What is BM?
A patient has bilateral lower-extremity edema, crackles in both lungs, and shortness of breath when lying flat. The provider documents this diagnosis.
What is CHF?
Following a motor vehicle accident, the emergency physician orders cross-sectional imaging to rule out an intracranial bleed.
What is CT?
Before electronically prescribing oxycodone for postoperative pain, the provider's registration with this federal agency is verified.
What is DEA?
A patient returns three months after their annual physical for blood pressure management. The provider bills the visit using the patient status.
what is EP?
The provider instructs a patient to increase oral intake after mild dehydration and writes this abbreviation in the care instructions.
What is Bib?
A patient with a 40-pack-year smoking history has chronic productive cough, wheezing, and decreased oxygen saturation during today's visit.
What is COPD?
While waiting in the lobby, a patient suddenly collapses, is unresponsive, and has no detectable pulse. The healthcare team immediately begins this emergency intervention.
What is CPR?
A patient asks which federal agency reviewed the safety and effectiveness of a newly released medication before it reached pharmacies.
What is FDA?
Although a patient has diabetes, hypertension, and asthma, the provider documents "persistent abdominal pain for two days" under this section of the chart.
What is CC?
During wound care, the provider documents a moderate ______ of serosanguineous drainage on the dressing.
What is amt?
A patient's screening test is positive for the virus that attacks CD4 T cells, but they have not developed severe immune deficiency.
What is HIV?
A patient with abnormal uterine bleeding is scheduled for a procedure that removes tissue from the uterine lining for both treatment and biopsy.
What is D&C?
A patient is instructed to avoid all food and caloric drinks for at least eight hours before having their blood drawn to evaluate glucose metabolism.
What is FBS?
A patient reports a previous appendectomy, seasonal allergies, and a family history of colon cancer before today's examination. These details become part of the patient's ______.
What is Hx?
A patient with influenza is advised to rest and increase this to prevent dehydration.
What is Fl?
Years after an untreated viral infection, a patient develops Pneumocystis pneumonia and a critically low CD4 count. The provider documents this diagnosis.
What is AIDS?
Because a pregnant patient's urine repeatedly shows glucose, the provider orders this diagnostic test to confirm or rule out gestational diabetes.
What is GTT?
After reviewing the patient's symptoms, physical examination, laboratory findings, and imaging results, the provider records the final conclusion in the medical record using this abbreviation.
What is Dx?