Unit 1: Charting Terms

Cephalic

Cephalic

head

Contusion

bruise

Syncope

fainting/loss of consciousness

Intractable

hard to control/stop

Emesis

vomitting

Hypertensive

high blood pressure

Tachypnea

rapid and shallow breathing

Diaphoresis

sweating

Febrile

feverish/fever

Auscultate

examine by listening

Palpate

examine by touch/feeling

Prophylactic

preventative

Analgesics

medication to relieve pain

Bolus

large dose or meal size amount

Enteral

nutrition delivered via the gut, in a chart, it usually means delivered by tube into the gut Intravenous - within a vein, fluids delivered via access to the veins

Edematous or edema

swollen with fluid

Laceration

a cut to the skin

Cellulitis

skin infection causing swelling & redness, often caused by bacteria

Chronic

persistent, long-term

Obstruction

blockage of a tube

Benign

non cancerous

Tumor

mass of tissue

Biopsy

procedure to remove a piece of tissue

Excised

surgically remove

Prognosis

predicted level of improvement or recovery

ICU

intensive care unit

Ax

assessment

yo

year old

♂

Male

♀

Female

DOB -

date of birth

Tx

transferred or treatment

c̅

with

R or L

right or left

#/fx

fracture

MVA

motor vehicle accident

Ortho

orthopedic

Sgx

surgery

Extubation

removal of a breathing tube for mechanical ventilation

Intubtion

placement of a breathing tube for mechanical ventilation

SOB

shortness of breath

2o (degree)

secondary to

PE

pulmonary (lungs)

embolism

blood clot blocking a blood vessel

VSS

vital signs stable

Rx

prescription

PMHx

previous medical history

SSRI

selective serotonin reuptake inhibitors (a class of drugs for depression and anxiety)

OTC

over the counter

Hs

evening

PRN

as needed (from the latin term pro re nata)

GERD

gastroesophageal reflux disease

Neuro

referring to the nervous system

PERL

pupils equal and reactive to light

Resp

referring to the respiratory system

T

temperature

RR

respiration rate

SpO2

oxygen saturation

CV

referring to the cardiovascular system

BP

blood pressure

HR

heart rate

GI

referring to the gastrointestinal system

BM

bowel movement

TID

three times daily

GU

referring to the genitourinary area of the body (bowel/reproductive)

u/o

urinary output

Cc

cubic centimeter which is equivalent to millilitre

Meds

medications

Antro

anthropometric data (body measurements)

Ht

height

Wt

weight

BMI

body mass index (kg/m2)

IBW

Ideal body weight - written as a range

Bid

twice daily

Quid

four times daily

DNR

do not resuscitate

Sx

symptoms

Dx

diagnosis

CC

cheif complaint

ID

infectious disease

NKDA

no known drug allergies

AKI

acute kidney injuryI

D/C

discharge (send patient home or to another facility)

MI

myocardial infarction (heart attack)

CVA

cerebrovascular attack (stroke)

HTN

hypertension (high blood pressure)

FLK

funny looking kid, this is inappropriate to use, indicates dysmorphic features in a child that may reveal a genetic mutation

Inflammation

Swelling

MRI

magnetic resonance imaging (3D images of anatomy)

Malignant

Cancerous

Acute

with sudden onset and often sever

Invasive

body is being entered by a needle/scope/tube/device, healing/recovery may be necessary (opposite of noninvasive)