1
Q
ADL
A
activities of daily living
2
Q
ASAP
A
As soon as possible
3
Q
ax
A
Axillary
4
Q
BE
A
Barium enema
5
Q
bx
A
Biopsy
6
Q
CABG
A
Coronary artery bypass graft
7
Q
CAM
A
Complementary and alternative medicine
8
Q
CC
A
Chief complaint
9
Q
c/o
A
Complains of
10
Q
CSF
A
Cerebrospinal fluid
11
Q
CPAP
A
Continuous positive airway pressure
12
Q
cx
A
Cervix
13
Q
D&C
A
Dilation and curettage
14
Q
drsg, dsg
A
Dressing
15
Q
ECP
A
Emergency contraceptive pill
16
Q
EEG
A
Electroencephalogram
17
Q
ERT
A
Estrogen replacement therapy
18
Q
ETOH
A
Ethyl alcohol
19
Q
FB
A
Foreign body
20
Q
FH
A
Family history
21
Q
fx
A
Fracture
22
Q
GIFT
A
Gamete intrefallopian transfer
23
Q
GP
A
General practitioner
24
Q
grav,gravida
A
Pregnancy
25
GU
Genitourinary
26
H&P
History and physical
27
HEENT
Head, eye, ear, nose, throat
28
HRT
Hormone replacement therapy
29
hs
Hour of sleep, bedtime
30
I&D
Incision and drainage
31
LPN
Licensed practical nurse
32
IVF
In vitro fertilization
33
LVN
Licensed vocational nurse
34
Mets
Metastasis
35
N&V
Nausea and vomiting
36
NKA
No known allergies
37
NKDA
No known drug allergies
38
NPO
Nothing by mouth
39
NVD
Nausea, vomiting, diarrhea
40
OC
Oral contraceptive
41
os
Opening
42
P
Pulse
43
OCP
Oral contraceptive pill
44
Para
Live births
45
PE, px
Physical examination
46
PERLA
Pupils equally reactive to light and accommodation
47
PH
Past history
48
R
Respiration
49
r/o
Rule out
50
ROM
Range of motion
51
Which of the following is added to code for a procedure that was extemsive, unusual, or required an assistant?
A 2-digit modifier
A modifier is an addition to a procedure code. It indicates unusual circumstances related to the procedure. It consists of 2 digits and is added to the main code after a hyphen.
52
An established patient is defined as
A patient who has been seen in the past 3 years.
An established patient is a patient who has been seen by the same provider or the same group of providers over time.
53
What is the format of most CPT codes?
6 digit codes.
Procedure codes are a means to classify the type of care given to a patient. The CPT manual provides a 5 digit code for each procedure for each or service a provider may perform.
54
The ICD-9 code that identifies an encounter other than illness or injury related is a(n)
V code
A v code is used when a patient is not currently I'll or to explain problems that influence a patients current injury, illness, or condition.
55
All ICD-10 codes contain
3-7 alphanumeric digits.
IDC-10 codes consist of 3-7 alphanumeric digits. The first digit is alphabetic, the second is numeric, and digits 3-7 are either.
56
All of the following are considered a tort except
Breach of contract
A tort is a civil wrong committed against another or property. A tort can be unintentional or intentional.
57
When the release of medical records is authorized, the MA should
Give the pt a copy of the original records.
The pt owns the information in the medical record, but the physician owns the record
58
Which is not a criterion for establishing negligence
Informed consent.
Negligence is the commission of an act that a prudent person would not do. Duty owed, dereliction of duty, direct cause, and damages make up for the "4 Ds" of negligence.
59
The MAs signature on an informed consent form means that the MA
Verified the pts signature
A physician must have consent to treat a pt. this consent can be implied which is sufficient for procedures that involve little risk, or this consent can be informed when more complex procedures are involved. Informed consent implies an understanding of what is to be done, why is it to be done, risks involved, expected benefits, and alternative treatments. This should be done by discussion between the pt and physician, and a form may be signed. The MA witnesses the signature of the pt on this form by signing and dating.
60
The initial report for a workers compensation claim should be filed
Immediately after the initial visit
The first report of the injury should be completed in quadruplaticate at the first visit and distributed to the pts chart, employer, compensation carrier, and the state workers compensation board. Filing deadlines vary by state, but they generally range from 24 hours to 10 days after the initial visit.
61
When a physician accepts a pt for treatment, the physician has a duty to
Use care, diligence, and skill in treatment.
A duty is an obligation or commitment to act in a certain way. The physician has a duty to do no harm, act to create good, meet the pts reasonable expectation, and tell the truth.
62
Which of the following pts would require a legal agent to consent to surgery
A 6 year old child
Consent is voluntary permission that is granted by someone who is legally able to do so to receive medical treatment. A minor requires the consent of a parent or guardian.
63
When a physician treats a Medicaid pt, the physician agrees
To accept the fee approved by Medicaid as payment in full.
Medicaid is a federal insurance program admits reed each state and available to patients with income below the poverty level. A physician who elects to treat a Medicaid pt must accept the reimbursement as pay,net in full without further billing the pt.
64
Rendering care to a pt without consent could result in a charge of
Battery
Battery is defined as intentional physical contact with another without that persons consent. A physician who fails to secure some formal expression of consent before treating a pt could be charged with trespass or battery.
65
A commitment or obligation to act in a certain way is a(n)
Duty
A duty is the obligation or commitment of a person to act in a certain ways. It is a basic principle of ethics- judgement of right and wrong. Duties include beneficence, nonmaleficence, veracity, fidelity, and justice.
66
SOAP
Subjective, objective, assessment, plan
67
Stat
Immediately
68
sx
Symptoms
69
T
Temperature
70
T&A
Tonsilloadenoidectomy
71
TLC
Tender loving care
72
TSE
Testicular self examination
73
tx
Treatment, therapy
74
UCHD
Usual childhood diseases
75
vo
Verbal order
76
VS
Vital signs
77
WDWN
Well developed, well nourished
78
WNL
Within normal limits
79
AIDS
Acquire immune deficiency syndrome
80
ADD
Attention deficit disorder
81
ALL
Acute lymphoblastic leukemia
82
AMI
Acute myocardial infarction
83
ASHD
Arteriosclerotic heart disease
84
BPH
Benign prostate hyperplasia/ hypertrophy
85
CA, ca
Cancer
86
CAD
Coronary artery disease
87
CHF
Congestive heart failure
88
COPD
Chronic obstructive pulmonary disease
89
CTS
Carpal tunnel syndrome
90
CVA
Cerebral vascular accident
91
DJD
Degenerative joint disease
92
DLE
Discoid lupus erythematosus
93
DT
Delirium tremens
94
DVT
Deep vein thrombosis
95
FTT
Failure to thrive
96
GAD
Generalized anxiety disorder
97
Gc
Gonococcus
98
GERD
Gastroesophageal reflux disease
99
HPV
Human papillomavirus
100
IBS
Irritable bowel syndrome
101
IDDM
Insulin dependent diabetes mellitus
102
MI
Myocardial infarction
103
NIDDM
Non insulin dependent diabetes mellitus
104
OA
Osteoarthritis
105
OM
Otitis media
106
PID
Pelvic inflammatory disease
107
POCS
Polysystic ovary syndrome
108
PMDD
Premenstual dysphoric disorder
109
RA
Rheumatoid arthritis
110
RAD
Reactive airway disease
111
RDS
Respiratory distress syndrome
112
RSV
Respiratory syncytial virus
113
SAD
Seasonal affective disorder
114
SARS
Severe acute respiratory syndrome
115
SLE
Systemic lupus erythematosus
116
SOB
Shortness of breathe
117
TMJ
Temporomandibular joint
118
URI
Upper respiratory infection
119
aa
Of each
120
a
Before
121
ac
Before meals
122
AD
Right ear
123
Ad lib
As desired
124
amp
Ampule
125
amt
Amount
126
aq
Water
127
AS
Left ear
128
ASA
Aspirin
129
AU
Both ears
130
NSAIDS
Nonsteroidal anti inflammatory drug
131
OD
Right eye
132
os
Mouth
133
OS
Left eye
134
OU
Both eyes
135
pc
After meals
136
po
By mouth
137
qod
Every other day
138
SL
Sublingual
139
AP
Anterior/posterior
140
BaS
Barium swallow
141
BUN
Blood urea nitrogen
142
CT
Computed tomography
