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Jane Dares Record

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Submitted By Haresh
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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 diseases. | States the classification of coding use | Admission SummarySheet | 2. CM | Clinical Modification | Classification of coding use | Admission Summary Sheet | 3. N/A | Not Available | This information concerning the patient is not available | Admission Summary Sheet | 4. ER | Emergency Room | States where the patient was taken for medical care | History & Physical | 5. C/O | Complains of | She made complain of | History & Physical | 6. SOB | Shortness of breath | Symptoms she was having | History & Physical | 7. mg | Milligram | The dosage of medication used | History & Physical | 8. po | By mouth | Method the patient will take her meds | History & Physical | 9. tid | Three times a day | The amount of times the patient will take her medication a day | History & Physical | 10. qd | Everyday | The frequency the patient needs to take her medication | History & Physical | 11. qod | Every other day | Skip a day then take another dose | History & Physical | 12. qhs | Every day at hours of sleep | A specific time the patient needs to use her medication | History & Physical | 13. tabs

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