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It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. [ citation needed ] [ 1 ] The chief complaint is a concise statement describing the symptom , problem, condition , diagnosis , physician -recommended return, or other reason for a medical encounter. [ 2 ]
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 main discussion of these abbreviations in the context of drug prescriptions and other medical prescriptions is at List of abbreviations used in medical prescriptions. Some of these abbreviations are best not used, as marked and explained here.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
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").
Abbreviation Meaning q: each, every (from Latin quaque) q15: every 15 minutes q6h q6° once every 6 hours q2wk: once every 2 weeks qAc Before every meal (from Latin quaque ante cibum) q.a.d. every other day (from Latin quaque altera die) QALY: quality-adjusted life year: q.AM: every day before noon (from Latin quaque die ante meridiem) q.d.
Use of abbreviations, such as those relating to the route of administration or dose of a medication, can be confusing and is the most common source of medication errors. [2] Use of some acronyms has been shown to impact the safety of patients in hospitals, and "do not use lists" have been published at a national level in the US. [4]
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...