Essay about module 4 PPA

2319 Words Mar 18th, 2014 10 Pages

Letters Represent
Context Definition or Application within the Patient’s Chart
Source Document
From Jane’s Dare Medical Record found on bottom of Medical Record pages…
1. ICD
International Classifications of Diseases, Ninth Revision
Published by WHO This is a systematic classification of diagnosis codes. These codes are numeric and alphanumeric codes that represent medical diagnoses


2. CM
Clinical Modification
This abbreviation out of context belongs collectively as the ICD-9-CM
These codes are added to ICD codes and can be used for diagnosis or procedure.

3. N/A
Not Available
This abbreviation means not
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Utilizes front wheeled walker with assistance of 1-2. Strength training, bed mobility and transfer training.
Physician Orders and Progress Notes
24. HCL
Hydrochloric acid
It is formed by dissolving gaseous hydrogen chloride with water.

Jane was prescribed Nortriptyline HCL 10 mg po qd
Physician Orders and Progress Notes
25. VO
Voice Over
The orders were giving verbally by the doctor.

Jane was given the two step mantoux
Standing orders
VO Dr. Archibald M. Graham
Physician Orders and Progress Notes
26. >
Greater than
Whats on the left is greater than whats on the left.

Doctor orders ACHING/FEVER: Acetaminophen 650 mg. po prn /fever > 100 po or tympanic 101 rectal.
Physician Orders and Progress Notes
27. MOM
Milk of magnesia. a common component of antacids and laxatives.

Jane needed bowl management so the doctor ordered MOM 30 cc po q.d. Prn.
Physician Orders and Progress Notes
28. UA
Laboratory analysis of urine, used to help diagnose disease or detect a specific substance.

The doctor order catheterization: straight catheterize prn for UA.
Physician Orders and Progress Notes
29. GI
pertaining to the stomach and intestine

The doctor ordered GI DISTRESS: Antacid (pharmacy stock) 1 teaspoon po q4h prn.
Physician Orders and Progress Notes
30. IM
Internal medicine the branch of medicine concerned with the study of the physiologic and pathologic characteristics
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