Jane Dares Health record Abbrev.

Decent Essays
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.
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
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Head, Ears, Eyes, Nose, Throat
Difficult time with exam of head, ears, eyes, nose and throat.
Physical Exam// History & Physical
17. IV
Antibiotics prescribed to be administered Intravenously
Plan/ History & Physical
18. O2
Oxygen prescribed to assist in breathing
Plan/ History & Physical
19. EKG
Test showing electrical activity of the heart, not provided

Transfer Form
20. CBC
Complete Blood Count
Blood test/ labs provided
Transfer Form
21. ADL’s
Activities of Daily Living
In need of 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
Physical therapy prescribed for Jane
Physicians Orders
24. HCL
Prescribed 10mg Nortriptyline HCL by mouth 1X a day
Physicians Orders
25. VO
Verbal Orders
Orders given verbally by Dr. Graham
Physicians Orders
26. >
Greater Than/ higher
If fever is greater than 100 given by mouth or ear 650mg Acetaminophen
Physicians Orders
27. MOM
Milk of magnesia
Administer 30cc Milk of magnesia by mouth as needed daily
Physicians Orders
28. UA urinalysis Catheterize daily as needed to assist in urination

Physicians Orders
29. GI
Prescribed Antacid 1 teaspoon by mouth every 4 hours as needed for stomach discomfort
Physicians Orders
30. IM
Intra Muscular
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