EHR Vocab; C4 D5

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16 Terms

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Ht
height
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Wt
weight
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BP
blood pressure
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P/HR
pulse/heart rate
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T
temperature
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R
respirations
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SPO2
pulse oximetry
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NKA
no known allergies
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NKDA
no known drug allergies
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MRN
medical record number
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Diagnostic
Process of identifying and determining the cause of disease or condition
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Medication order
Legal instruction from a licensed healthcare provider authorizing the administration of a drug to a pt
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Progress note
clinical document in a pt chart about their health status, treatment progress, and clinical events like a hospital stay
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Demographics

Non-clinical pt information like name, DOB, and insurance information

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Care plan
outlines the specific healthcare needs, goals, and interventions for a pt
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Medical history
Record of a pt’s past and present health conditions