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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).
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
Abbreviations of weights and measures are pronounced using the expansion of the unit (mg = "milligram") and chemical symbols using the chemical expansion (NaCl = "sodium chloride"). Some initialisms deriving from Latin may be pronounced either as letters ( qid = "cue eye dee") or using the English expansion ( qid = "four times a day").
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.
Abbreviation Meaning Δ: diagnosis; change: ΔΔ: differential diagnosis (the list of possible diagnoses, and the effort to narrow that list) +ve: positive (as in the result of a test) # fracture: #NOF: fracture to the neck of the femur ℞ (R with crossed tail) prescription: Ψ: psychiatry, psychosis: Σ: sigmoidoscopy: x/12: x number of ...
Medication Administration Record. A Medication Administration Record [1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
Acronyms are very commonly used in healthcare settings. [1] They are formed from the lead letters of words relating to medications, organisations, procedures and diagnoses. [2] They come from both English and Latin roots. [2] [3] Acronyms have been described as jargon. [1] and their use has been shown to impact the safety of patients in ...
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