Medical Terminology

1. Medical Terminology 1.01 Identify abbreviations commonly used in the health care setting.

2. Medical abbreviations • Shortened forms of words • They are an efficient way of communicating quickly and concisely with other health care workers. • Health care workers use abbreviations to convey information about their patients/clients.

3. Medical abbreviations • help save time and space on medical documents. • Also known as short hand • usually just letters but #s are sometimes used. Examples am (before noon) H20 (water)

4. Medical abbreviations • May be combined to give orders or directions • Varies depending upon facility or culture • Periods may or may not be used Example: a.m. or am

5. Medical abbreviations • Each individual is responsible for making sure that they are using the appropriate abbreviations for their agency. • Incorrect / illegal abbreviations could lead to misunderstandings, confusion or anger.

6. Abbreviation Usage • Be considerate when you use an abbreviation • Your patients do not always know what the abbreviations mean. Ex: NPO posted over the head of the bed (HOB) • As a HCP you know what it means but the patient doesn’t , you need to explain to the pt. what it means.

7. Incorrect and illegal abbreviations • Sometimes used by personnel due to not knowing facilities approved list. • Ex: Jim is a FLK. • David Snow – 48 yoa SWM, dyspnea, s.o.b., HA, chest pain & N & V.

8. Transcribe to abbreviated format Suzanne to be admitted to the hospital through the emergency room department. She came in complaining of headache, difficulty breathing, and chest pain. She has a past history of heart attacks, stroke and high blood pressure. Orders are as follows: • Monitor blood pressure every two hours • Complete blood count, potassium, sodium and magnesium levels • Chest x-ray and magnetic resonance imaging

9. Abb. Written order Suzanne adm. through ER dept. Pt. c/o HA, dyspnea, and chest pain. Past hx. Of MIs, CVA & HBP. Orders are as follows: • ck BP Q2H • CBC, K, Na and Mg levels • Chest XR & MRI

10. TPR & BP ASAP Stat CA HA WNL Ad lib am Rx tsp q2h mL EEG VS Commonly used Abb.

11. abd - abdomen amb - ambulate/walk bid - twice a day CCU - coronary care unit or critical CVA - cerebrovascular accident / stroke po - by mouth OOB/oob - out of bed OR - operating room ER - emergency room PEDS - pediatrics P.T. - physical therapy Identification of common medical abbreviations

12. Discussion time and hands on practice. FYI : You already use abbreviations. Ex: text messaging, email, time, etc…

13. References • Health Careers Science Exploration Textbook – Chapter 7 pgs: • NCDPI