Jane Dares Health record Abbrev.
Instructions
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
As it pertains to Jane Dare’s disease
Admission Summary
2. CM cardiomyopathy structural or functional disease of heart muscle
Admission Summary
3. N/A
Not Applicable
No answer necessary
Admission Summary
4. ER
Emergency Room
Arrived at Emergency room
History & Physical
5. C/O
Complains of
Reason for coming to ER
History & Physical
6. SOB
Shortness of Breath
Having difficulty breathing
History & Physical
7. mg
Milligram
1/1000 of a gram
Takes 25mg Capoten by mouth 3X’s a day
Medications/ History & Physical
8. po
Peri/osteum
Takes Furosemide 40mg by Mouth daily
Medications/ History & Physical
9. tid times interval difference
Takes 25mg Capoten by mouth 3X’s a day
Medications/ History & Physical
10. qd quantum dot
Administer MOM 30cc daily by mouth as needed
Medications/ History & Physical
11. qod every other day /quaque altera die
Takes 0.125mg Digoxin by mouth every other day
Medications/ History & Physical
12. qhs quantity at hour of sleep
Takes 10mg Nortriptyline HCL by mouth at bedtime
Medications/ History & Physical
13. tabs
Tablets
Takes Tylenol 325mg tablets as needed for pain
Medications/ History & Physical
14. prn pro re nata/ as needed
Takes Tylenol 325mg tablets as needed for pain
Medications/ History & Physical
15. cc
Cubic
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
As it pertains to Jane Dare’s disease
Admission Summary
2. CM cardiomyopathy structural or functional disease of heart muscle
Admission Summary
3. N/A
Not Applicable
No answer necessary
Admission Summary
4. ER
Emergency Room
Arrived at Emergency room
History & Physical
5. C/O
Complains of
Reason for coming to ER
History & Physical
6. SOB
Shortness of Breath
Having difficulty breathing
History & Physical
7. mg
Milligram
1/1000 of a gram
Takes 25mg Capoten by mouth 3X’s a day
Medications/ History & Physical
8. po
Peri/osteum
Takes Furosemide 40mg by Mouth daily
Medications/ History & Physical
9. tid times interval difference
Takes 25mg Capoten by mouth 3X’s a day
Medications/ History & Physical
10. qd quantum dot
Administer MOM 30cc daily by mouth as needed
Medications/ History & Physical
11. qod every other day /quaque altera die
Takes 0.125mg Digoxin by mouth every other day
Medications/ History & Physical
12. qhs quantity at hour of sleep
Takes 10mg Nortriptyline HCL by mouth at bedtime
Medications/ History & Physical
13. tabs
Tablets
Takes Tylenol 325mg tablets as needed for pain
Medications/ History & Physical
14. prn pro re nata/ as needed
Takes Tylenol 325mg tablets as needed for pain
Medications/ History & Physical
15. cc
Cubic