Abbreviations
BID
TID
Twice per day
Three times a day
QD
once per day
What is an Assessment?
examining a situation so that it can be evaluated
What is an Objective?
descriptions based on facts about a situation
What is Sim’s position?
body position in which a person is lying on left side with the upper knee flexed and raised towards the chest
Fx
fracture
R/O
rule out
What is Auscultation?
the act of listening to the internal sounds of the body with a stethoscope
What is a Plan?
provides directions and serves as a guide to delivering individualized, holistic care
What is a Snellen chart?
What is SOAP Notes?
chart used to assess visual acuity and check for myopia and hyperopia
Subjective, Objective, Assessment, Plan for patient care
NPO
nothing by mouth
ROM
WNL
range of motion
within normal limits
What is a Diagnosis?
physician’s determination of an illness
What is a Prognosis?
a projection of the likely course and outcome of a disease and the potential for recovery
What is a Subjective?
What is a Supine position?
descriptions based on feelings or opinions about a situation
a body position in which a patient is lying flat on their back with the arms at each side
po
by mouth
Rx
s/sn
medical prescription
signs/symptoms
What is Fowler’s position?
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
What is a Prone position?
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
What is a Symptom?
Therapeutic
a piece of subjective information about a disease or condition; is based on a person’s feelings or opinions
having a healing effect on the body
px
tx
pain
treatment
VS
T
P
R
BP
vital signs
Temperature
Pulse
Respirations
Blood Pressure
What is an Inspection?
the visual examination of a body part
What is a Sign?
a piece of objective or factual information about a disease or a condition
What is Trendelenburg position?
What is Visual Acuity?
a body position in which the patient lies on their back and the legs are raised above the head
an assessment of visual clarity using a Snellen chart