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[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
Pronunciation follows convention outside the medical field, in which acronyms are generally pronounced as if they were a word (JAMA, SIDS), initialisms are generally pronounced as individual letters (DNA, SSRI), and abbreviations generally use the expansion (soln. = "solution", sup. = "superior").
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
Past medical history (see also medical history) PSI: Pneumonia severity index: PSP: phenylsulphtalein: PSS: progressive systemic sclerosis (see scleroderma) PSVT: paroxysmal supraventricular tachycardia: PT: prothrombin time physical therapy (physiotherapy) Pt. patient (from Latin patiens, meaning "one who endures" or "one who suffers") PTA
This is a list of abbreviations used in medical prescriptions, including hospital orders (the patient-directed part of which is referred to as sig codes).This list does not include abbreviations for pharmaceuticals or drug name suffixes such as CD, CR, ER, XT (See Time release technology § List of abbreviations for those).
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
statement of medical necessity SMS: senior medical student SMT: spinal manipulative therapy: SMV: superior mesenteric vein: SN: student nurse skilled nursing SNB: sentinel node biopsy (ductal carcinoma) SNF: skilled nursing facility: SNHL: sensorineural hearing loss: SNP: sodium nitroprusside single nucleotide polymorphism: SNRI: serotonin ...
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...