Essay on module 4 PPA

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PPA-1-ABBREVIATIONS CHART

Abbreviation
Letters Represent
Context Definition or Application within the Patient’s Chart
Source Document
From Jane’s Dare Medical Record found on bottom of Medical Record pages…
1. ICD
International Classifications of Diseases, Ninth Revision
Published by WHO This is a systematic classification of diagnosis codes. These codes are numeric and alphanumeric codes that represent medical diagnoses

ADMISSION SUMMARY

2. CM
Clinical Modification
This abbreviation out of context belongs collectively as the ICD-9-CM
These codes are added to ICD codes and can be used for diagnosis or procedure.

ADMISSION SUMMARY SHEET- FACE SHEET
3. N/A
Not Available
This abbreviation means not …show more content…
Physician Orders and Progress Notes
31. D/T
Diphtheria/Tetanus

This refers to the standing order for administration of the Diphtheria/Tetanus series if needed.

Tetanus series, give:

0.5 cc D/T initially

Physician Orders and Progress Notes
32. DT
Diphtheria Tetanus diphtheria-tetanus vaccine

Doctor order 2.0.5 cc DT 4-8 weeks later after 0.5 cc D/T initially.

Physician Orders and Progress Notes
33. DP
Diphtheria Pertussis vaccine that protects against diphtheria, tetanus (lockjaw), and pertussis (whooping cough).

Doctor ordered 3.0.5 cc DP 6 months later.
Physician Orders and Progress Notes
34. UTI
Urinary tract infection
An infection that affects part of the urinary tract

Doctor order lab work: Dipstrick for leukocytes and nitrates prn symptoms or UTI.
Physician Orders and Progress Notes
35. OT
Occupational Therapy evaluate and treat patients to improve functioning in daily life activities.

Doctor ordered REHABILITATION SERVICES (PT. OT.
SPEECH): Screen/evaluate and treat as indicated.
Physician Orders and Progress Notes
36. LOA Leave of absence
A period of time that one must be away from his/her primary job, while maintaining the status of employee.

Doctor ordered THERAPEUTIC LOA: May go on therapeutic leave of absence with current meds according to facility policy. Physician Orders and Progress Notes
37. N/G
Nasogastric Tube

A
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