Medical Terminology Information Sheet

Medical Terminology Information Sheet : Medical Chart Organization: Demographics and insurance Flow sheets Physician Orders Medical History Terms: Visit notes CC Chief Complaint of Patient Laboratory results HPI History of Present Illness Radiology results ROS Review of Systems Consultant notes PMHx Past Medical History Other communications PSHx Past Surgical History SHx & FHx Social & Family History Types of Patient Encounter Notes: Medications and medication allergies History and Physical NKDA = no known drug allergies o PE Physical Exam o Lab Laboratory Studies Physical Examination Terms: o Radiology PE= Physical Exam y x-rays (+) = present y CT and MRI scans (-) = Ф = negative or absent y ultrasounds nl = normal o Assessment- Dx (diagnosis) or wnl = within normal limits DDx (differential diagnosis). if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology : unclear) CBC = complete blood count o Plan- Further tests, Chem 7 (or Chem 8, 14, 20) =.

MR mental retardation MR# medical record number NA not available Na+ no applicable NBS no bowel sounds Neg negative Ng naso-gastric NKA no known allergies NMR nuclear magnetic resonance No. number Noct night norm normal NPN non-protein nitrogen NPO nothing by mouth nullip nulleparous (no pregnancies) o.d. once a day

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  Mental, Retardation, Mental retardation

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