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Understanding Medical Terminology Abbreviations for Effective Charting and Communication

This guide explores the significance of medical terminology abbreviations in healthcare. These shortened forms simplify charting, orders, and directions, enabling clear and efficient communication among professionals. Through examples such as Hx+HIV, COPD, and DNR orders, we illustrate how combining abbreviations creates informative "sentences." Learn how to interpret essential terms like Pt c/o RLQ pain and EMT to ER approx. 3 min., and enhance your understanding of patient documentation practices in clinical settings.

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Understanding Medical Terminology Abbreviations for Effective Charting and Communication

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  1. Medical Terminology

  2. Abbreviations • Shortened forms of words • Used in charting, orders, & directions • Combine abbreviations to forms “sentences”

  3. Examples • Hx+HIV; COPD; -TB; HOH OD; DNR order • Ckchol; Send CBC to Lab; Ffl • Pt c/o RLQ pain; ROM bid; GTT • NB neg HIV; +CP; XR; CT scan • Low K; jt pain; Hx – IDDM & TIA • EMT to ER approx. 3 min.; CPR started; pt DOA

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