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Jane Dare

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Submitted By katraeb
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Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report. Abbreviation | Letters Represent | Context Definition or Application within the Patient’s Chart | Source Document | 1. ICD | International classification of disease | Jane dare’s disease | Admission summary | 2. CM | Cardiomyopathy | Structural or functional disease of heart muscle | Admission summary | 3. N/A | N- NotA- Applicable | Not availableNo answer | Admission summary | 4. ER | E-EmergencyR- Room | Arrived at emergency room | History and physical | 5. C/O | Complains of | Reason for Jane to go to the ER | History and physical | 6. SOB | Shortness of Breath | Having difficulty breathing | History & physical | 7. mg | Milligrams | 1/1000 of a gram | 25mg capoten orally 3x a day | 8. po | Peri/osteum | Takes furosemide 40mg orally daily | Medications/ history & physical | 9. tid | Times interval difference | 25mg capoten by mouth 3 times a day | medications | 10. qd | Quantum dot | MOM 30cc daily by mouth as needed | medications | 11. qod | Every other day-Quaque altera die | 0.125mg digoxin by mouth every other day | medications | 12. qhs | Quantity at hour of sleep | Takes 10mg nortriptyline HCL by mouth at bedtime | medications | 13. tabs | tablets | Takes Tylenol 325mg tablets as needed for pain | medications | 14. prn | Pro re nata- as needed | Takes Tylenol 325mg tablets as needed for pain | medications | 15. cc | Cubic centimeters | Takes 30CC magnesia by mouth daily as needed | medications | 16. HEENT | Head, eyes, ears, nose, throat | Difficult time with head, ears, eyes, nose & throat | Physical exam | 17. IV | Intravenous | Antibiotics prescribed to be administered intravenously | Plan/ history and physical | 18. O2 | oxygen | Oxygen prescribed to help breathing | History and physical | 19. EKG | electrocardiogram | Test that checks for problems with the electrical activity of your heart | Transfer form | 20. CBC | Complete Blood Count | Blood test/ lab report | Transfer form | 21. ADL’s | Activities of Daily Living | Needs help performing daily activities | Transfer form | 22. MSW | Master of Social Work | Title of social worker who performed screening | Social services screening | 23. PT | Physical Therapy | Jane needs physical therapy | Physicians orders | 24. HCL | hydrochloride | Prescribled nortriptyline HCL by mouth 1x a day | Physicians orders | 25. VO | Verbal Order | Orders given by Dr. Graham | Physicians orders | 26. > | Greater than | If fever is greater than 100 given by mouth or ear 650MG acetaminophen | Physicians orders | 27. MOM | Milk of magnesia | Administer magnesia by mouth as needed daily | Physicians orders | 28. UA | Urinalysis unstable angina | Catheterize needed to assist in urination | Physicians orders | 29. GI | Gastrointestinal | Prescribed antacid 1tsp by mouth every 4 hours as needed for stomach discomfort | Physicians orders | 30. IM | intramuscular | Prescribed | Physicians orders | 31. D/T | Diphtheria/tetanus series | To be administered to patient- never received D/T series First of series | Physicians orders | 32. DT | Diphtheria-tetanus full dosage (doesn’t contain pertussis) | Administered 4-8 weeks afterSecond in series | Physicians orders | 33. DP | Diphtheria- pertussis full dosage | Administered 6 months laterThird in series | Physicians orders | 34. UTI | Urinary tract infection | Test to be performed if UTI is present | Lab work/physicians orders | 35. OT | Occupational therapy | Assist Jane in everyday living | Physicians orders | 36. LOA | Leave of absence | Jane can leave for therapeutic reasons | Physicians orders | 37. N/G | Nasogastric Tube | Tube through the nose and down through the nasopharynx and esophagus into the stomach tube to be replaced as needed | Physicians orders | 38. G-tube | Gastrostomy tube | Tube inserted in the abdomen that delivers nutrition directly to the stomach tube | Physicians orders | 39. BP | Blood pressure | Vitals taken Blood pressure results 112/62 | Nurses progress notes | 40. P | pulse | Vitals taken/ pulse rate at 24 | Nurses progress notes | 41. R | Respirations | Vitals taken/ respiration rate | Nurses progress notes | 42. T | Temperature | Vitals taken/ temperature at 99 | Nurses progress notes | 43. CPR | Cardiopulmonary Resuscitation | Decision was made for no CPR with Jane and her husband | Nurses progress notes | 44. PERL | Pupils equal and reactive to light | Vitals were taken and PERL was good | Nurses progress notes | 45. NAS | No added salt | Jane has a diet with no salt- doesn’t like the food | Nurses progress notes | 46. CHF | Congestive heart failure | Chronic condition in which the heart is unable to pump out all of the blood that it receives | | 47. TO | Telephone order | Orders received by Dr. Graham over the phone to ok Jane’s transfer to St. Mary’s | Physicians orders | 48. PA | Pulmonary Arteries | Findings of Jane’s heart | | 49. POA | Person of Authority | Person able to approve treatments for Jane | Social Services | 50. BM | Bowel movement | Jane has been incontinent to make a bowel movement daily | X-ray report | 51. WCR/bca | WCR- Doctors InitialsBCA- Baseline Conclusion Assessment | WCR is the radiologist initialsBCA is the baseline conclusion assessments | X-Ray report |

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