Medical Receptionist HANDOUT #4 Acronyms – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – Ac: before meals ad lib: at will, as desired adm: admission, admitted ASAP: as soon as possible Bid: twice a day Bm: bowel movement BP: blood pressure BRP: bathroom privileges C: Centigrade, Celsius Cap: capsule CC: chief complaint c/o: complains of C02: carbon dioxide CPR: cardiopulmonary resuscitation CXR: chest x-ray Daily (entire word) d/c: discontinue or discharge ECG/ EKG: electrocardiogram EBL: estimated blood loss ER: emergency room Every other day (entire word) F: Fahrenheit Fb: foreign body fx: fracture gtt: drop-liquid measurement H & P: history and physical HR: heart rate hr: hour hs: hour of sleep (bedtime) H20: water I & O: intake and output • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • IDDM: insulin dependent diabetes mellitus IV: intravenous IM: intramuscular Magnesium Sulfate (entire word) mg: milligram ml: milliliter (do not use cc) Morphine Sulfate entire word) MVA: motor vehicle accident NPO: nothing by mouth NTG: nitroglycerin O2: oxygen post-op: postoperative (after surgery) pre-op: preoperative (before surgery) po: by mouth pt: patient prn: as needed pc: after meals qh: every hour qid: four times a day Rx: prescription sc/sq: subcutaneous s: without sx: symptoms s/s: signs and symptoms STAT: immediately SOB: short of breath tab: tablet TPR: temperature, pulse, respiration Unit: entire word) vs: vital signs Lead with zero: write 0.5mg not .5mg 1 DOWNTIME TIPS (DT) Prior to ALL types of Downtimes a. Post DT notices & remind staff time DT is starting b. Check DT kits for copies of each documents (make copies as needed) c. Listen for overhead announcements for start of DT MEDIPAC DT: a. Print Patient List to track incoming and outgoing patient movement b. When DT is over, Discharge and Transfer patients to correct locations. Refresh census c. Call Admitting if new admissions are not on census within 1 hour HEO/Wiz: a. Print extra patient labels in HEO/Wiz and EasyID (may use blue card and addressograph) b. Print OPC, CP Snapshot and CN Snapshot as needed c. Place extra POS on counter by MRs desk (1 copy should always be in chart) d. Round to retrieve written orders and fax Pharmacy their copy e. Complete DT Reqs for ancillary depts when orders are handwritten HED: a. Affix patient label on document or stamp paper documents with addressograph b. Print/ make copies of Flowsheets and deliver to nurses to chart care c. Admin-Rx DT: pick up computer generated MARs & give to RNs MEDIPAC Keyboard Tips ( do not use mouse) Pause/Break/Scroll Lock: back to menu Tab: Moves cursor forward Shift + Tab: Moves cursor backward Esc key: Reset key (removes stick man) F3: Goes back one screen in function F7: Turns page back : F8: Turns page forward F9: Same account or bed selection Type A to select a functions PAVILLIONS 1 VUH Adult Hospital 3 VCH Children’s Hospital 4 Heart & Vascular (7N, 5N, 5S, 6S, CCL, COBS) 5 Vanderbilt Psychiatric Hospital Discharge/ Depart in Error Discharge (IA) Depart (OT) 1. Type 0, then 12-digit account /Case # 2. Enter exact time patient is discharged 3. Enter 2 times for departures: a. Patient physically leaves b. Patient medically able to leave- get from RN 4. Disposition code: be sure to select “E” for alive pts Create Assignments in HED 1. 2. 3. 4. 5. 6. 7. 8. Click Create Assignment Provider Type: RN Care Relationship: Primary Nurse or CP Shift: Days / nights Back time 15 min, then uptime 15 min Search: Caregivers name Patients: hold Crtl to select more than one Click Assign 1. Call Admitting Dept to cancel 2. Orders lost in 4 hours 2