Clinical Documentation 30SCST 2MST 2MWT 6MWT 5TSST AAA AAROM Abd ABD ABG ABX ac ACH ACL ACLS A/D ADD ADA
Full Answer
What are abbreviations used for in medical terms?
Abbreviations, acronyms, and medical terminology are used for many conditions, and for instructions on medication prescribed by your doctor. This is a short list of common abbreviations you may have seen on a doctor's notepad; a prescription drug package or bottle; lab or other test results; or in your doctor's notes.
What are some medical abbreviations that are approved by the FDA?
Approved Medical Abbreviations The following is a list of approved medical abbreviations. In general, the use of abbreviations should be limited to this list. A&O x 3 - alert and oriented to person, place and time A&O x 4 - alert and oriented to person, place, time and event A-FIB - atrial fibrillation AAA - abdominal aortic aneurysm
How do I search for medical acronyms or abbreviations?
There is no standard or approved list used by health care professionals to search for medical acronyms or abbreviations. Therefore, it is important to understand the context in which the abbreviation or term has been used.
When did the JCAHO adopt the list of medical abbreviations?
In 2005, the JCAHO adopted a list of medical abbreviations that cannot be used by any JCAHO-accredited organizations and those seeking accreditation, which also apply to services that have been or are applying to be certified under the Disease-Specific Care Certification Program.
Is there a list of approved medical abbreviations?
There is no standard or approved list used by health care professionals to search for medical acronyms or abbreviations. Therefore, it is important to understand the context in which the abbreviation or term has been used.
Are abbreviations allowed in medical records?
Acronyms and abbreviations are acceptable in the medical record if they are commonly recognized. If a practice uses terminology that is not industry standard, it must maintain a list of the abbreviations with definitions and how they are used, and should submit this documentation anytime an audit is done.Mar 21, 2018
What are common medical abbreviations?
Common Medical Abbreviations & Terms CenterANED: Alive no evidence of disease. ... ARF: Acute renal (kidney) failure.cap: Capsule.CPAP: Continuous positive airway pressure. ... DJD: Degenerative joint disease. ... DM: Diabetes mellitus. ... HA: Headache.IBD: Inflammatory bowel disease.More items...
Which acronym is used for a type of medical charting?
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.
Is QD an approved abbreviation?
These abbreviations are listed below, along with their potential miscommunications, and the recommended alternative....Medical Abbreviations Officially Labeled “DO NOT USE”DO NOT USEPOSSIBLE CONFUSIONUSE THIS INSTEADQ.D., QD, q.d., qd (daily)with Q.O.D., QOD, q.o.d., qod (every other day)daily7 more rows
Is AC an approved medical abbreviation?
a.c.: Abbreviation on a prescription meaning before meals; from the Latin "ante cibum", before meals.
Is bid an approved abbreviation?
b.i.d. (on prescription): Seen on a prescription, b.i.d. means twice (two times) a day. It is an abbreviation for "bis in die" which in Latin means twice a day.
What is C in medical abbreviation?
The c is almost always lower-case. This symbol actually has a very simple meaning. A c with a line over it just means "with". This abbreviation is often used on patient charts and prescriptions, as well as information or notes written by medical professionals.Oct 23, 2017
What does TX mean in medical terms?
TreatmentDx - Diagnosis, Sx - Symptoms, Fx - Fracture, Tx - Treatment, Hx - History S/b-seen by. Sortable table. Abbreviation.
What is focus charting in nursing?
Focus Charting - is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action.
What does S P stand for?
Status postStatus post (S/P) is a term used in medicine to refer to a treatment (often a surgical procedure), diagnosis or just an event, that a patient has experienced previously, for example, "status post cholecystectomy", "S/P vaginal delivery", etc.May 21, 2021
What is charting by exception in nursing?
CHARTING BY EXCEPTION (CBE) or variance charting is a system for documenting exceptions to normal illness or disease progression, using a shorthand method of charting what's usual and normal. You make check marks or write your initials in certain places on the CBE flow sheets.
Medical Abbreviations
Medical abbreviations and acronyms are frequently used in the healthcare field.
Charting Abbreviations
Let’s begin with common abbreviations you might see associated with charting.
Vital Sign Abbreviations
Next we have abbreviations for vital signs, which will likely appear in charts as well.
Pharmacy Abbreviations
Let’s move on to abbreviations you might see associated with pharmacy.
What is HPS in medical terms?
A blood test for follicle stimulating hormone which is used to evaluate fertility in women. HPS: Hantavirus pulmonary syndrome. A type of contagious, infectious disease transmitted by rats infected with the virus. IBS: Irritable bowel syndrome (A medical disease that involves the gastrointestinal tract.)
What is the A/G ratio?
a/g ratio: Albumin to globulin ratio. ACL: Anterior cruciate ligament. ACL injuries are one of the most common ligament injuries to the knee. The ACL can be sprained or completely torn from trauma and/or degeneration.
What is the meaning of "failing to document a discontinued medication"?
Failing to document a discontinued medication. If the patient is supposed to be taken off a medication because of its adverse effects, you need to document that order promptly. A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer.
What does BMP stand for in a pulmonary amputation?
For example, someone with a pneumonia in both lungs might have abnormal bibasilar breath sounds. BKA: Below the knee amputation. BMP: Basic metabolic panel. Electrolytes (potassium, sodium, carbon dioxide, and chloride) and creatinine and glucose.
What to do when two patients with the same name start bleeding?
When you have two or more patients with the same name, be sure a different nurse is assigned to each patient; develop a system of flagging the patients’ names on charts and medication records. And check wristbands before you give medications. 5.
What is the H and H?
H&H: Hemoglobin and hematocrit. When the H & H is low, anemia is present. The H&H can be elevated in persons who have lung disease from long term smoking or from disease, such as polycythemia rubra vera.
What does TSH stand for in blood test?
TSH: Thyroid stimulating hormone. A blood test for TSH is used to diagnose thyroid disease. Use this list as a resource for common abbreviations and acronyms used in the health care community, to quickly search and answer your questions about those letters and numbers or other notes from professionals.
What is the A/G ratio?
a/g ratio: Albumin to globulin ratio. ACL: Anterior cruciate ligament. ACL injuries are one of the most common ligament injuries to the knee. The ACL can be sprained or completely torn from trauma and/or degeneration.
What does SIDS mean in medical terms?
SIDS: Sudden infant death syndrome. TSH: Thyroid stimulating hormone. A blood test for TSH is used to diagnose thyroid disease. Use this list as a resource for common abbreviations and acronyms used in the health care community, to quickly search and answer your questions about those letters and numbers of a drug your doctor has prescribed to you, ...
What does BMP stand for in a pulmonary amputation?
For example, someone with a pneumonia in both lungs might have abnormal bibasilar breath sounds. BKA: Below the knee amputation. BMP: Basic metabolic panel. Electrolytes (potassium, sodium, carbon dioxide, and chloride) and creatinine and glucose. BP: Blood pressure.
What is the H and H?
H&H: Hemoglobin and hematocrit. When the H & H is low, anemia is present. The H&H can be elevated in persons who have lung disease from long term smoking or from disease, such as polycythemia rubra vera.
What is HPS in a blood test?
A blood test for follicle stimulating hormone which is used to evaluate fertility in women. HAPE: High altitude pulmonary edema. HPS: Hantavirus pulmonary syndrome. A type of contagious, infectious disease transmitted by rats infected with the virus.
What does low hematocrit mean?
A low hematocrit level may signal anemia, or other conditions such as loss of blood, nutritional deficiency, bone marrow problems, and abnormal hematocrit.
What are some examples of personal abbreviations?
Some examples of personal abbreviations and other slang from actual charts are: “Guts and Butts”: your local gastroenterologist.
What does MS stand for in medicine?
Medication abbreviations “MS,” “MSO4,” and “MgSO4”: In the first instance, “MS” has been interpreted as morphine sulfate and magnesium sulfate when the other was intended. The other abbreviations have been confused for one another, so they both are prohibited.
What is the abbreviation for IU?
Instead of using the abbreviation “U,” the JCAHO requires substitution with the word “unit.”. IU (International Unit ): Has been mistaken for the abbreviation “IV” (intravenous) or the number “10” (ten). Substitute with “International Unit.”.