Medical Terminology Spine Diagnosis Documentation Charting

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SOAP Notes - StatPearls - NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK482263/

Current Medications, Allergies. Current medications and allergies may be listed under the Subjective or Objective sections. However, it is important that with any medication documented, to include the medication name, dose, route, and how often. …

Glossary of Spinal Terms - SpineUniverse

https://www.spineuniverse.com/anatomy/glossary-spinal-terms

Spinal Cord – The longitudinal cord of nerve tissue that is enclosed in the spinal canal. It serves not only as a pathway for nervous impulses to and from the …

Abbreviation List for Medical Record Documentation

https://madisonmemorial.org/wp-content/uploads/Abbreviation-List-for-Medical-Record-Documentation-V20.pdf

diag diagnosis diam diameter DIC disseminated intravascular coagulopathy dil. dilute or dissolve DIP distal interphalangeal joint disch discharge DISH Diffuse idiopathic …

Nurse Charting 101 | Berxi™

https://www.berxi.com/resources/articles/nurse-charting-101/

Narrative Notes. Narrative nurses notes are like a running log of everything that happened …

CHART Documentation Format Example - RC Health Services

https://instructor.rchealthservices.com/wp-content/uploads/2013/12/CHART-and-SOAP.pdf

performed. BACK/SPINE: No complaint. Palpation of the area finds no tenderness. The area was visualized by raising the Pts. Night shirt. No injury or abnormal findings were …

Medical Terminology Information Sheet - University of Illinois …

https://mfpweb.nursing.uic.edu/education/assessment/Common_Medical_Terminology.pdf

Medical Terms by Body System HEENT – Head, Ears, Eyes, Nose & Throat: Occipital – back of the head Photophobia – intolerant of light Phonophobia – intolerant of sounds …

75 Must-Know Medical Terms, Abbreviations, and …

https://www.sgu.edu/blog/medical/medical-terms-abbreviations-and-acronyms/

Medical terminology follows the same structural rules all language does, including use of prefixes and suffixes. You may be familiar with some of these from words …

Common Nursing Terms: A Cheat Sheet for New Nurses

https://www.rasmussen.edu/degrees/nursing/blog/common-nursing-terms/

Chart: The medical documentation that follows a patient throughout a healthcare facility. It includes medical history, diagnoses, test results, dosage and timing of medications, and …

Basic Medical Terminology: 100 Medical Phrases To Know

https://www.indeed.com/career-advice/career-development/basic-medical-terminology-list

This is a list of some informal terms often used by medical professionals: Afib: Atrial fibrillation, irregular and rapid heartbeats. Bagging: Helping a patient …

How to Read Your Radiology Report

https://www.radiologyinfo.org/en/info/article-read-radiology-report

Liver: Normal size and contour. There is a new 2 cm hypoattenuating focus in segment 8. Gallbadder is surgically absent. Biliary: No intra or extrahepatic biliary …

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