Medical Record Blunders

Rectal exam revealed a normal size thyroid. (Long

fingers?)
Exam of genitalia reveals that he is circus sized.

On the second day the knee was better and on the

third day it had completely disappeared.

She is numb from her toes down.

History and Physical: pp. 41-43

Progress Note (SOAP format): pp. 43-44
Prescription: pp. 73-76

What each form is for.

What are the component parts of each form.
What kind of information goes in each
component part.
The common abbreviations associated with
these forms.

S: subjective that which the patient describes

O: objective observable information, such as

test results, blood pressure readings, etc.

A: assessment progress and evaluation of the
effectiveness of the plan
P: plan decision to proceed or alter strategy

p.r.n.
ad lib.
noc.
a.m.
p.c.
NPO
q.1 h, q.1
q.i.d. (t.i.d.)

statim
pro re nata
ad libitum
noctis (nocte)
ante meridiem
post cibum
non/nihil per os
1 quaque hora
quarter in die (ter)

STAT
p.r.n.
ad lib
noc.
a.m.
p.c.
NPO
q.1 h, q.1
q.i.d. (t.i.d.)

h.s. (hour sleep or half-strength)

qd and q.o.d (s.i.d. and q.a.d.)
AD, AS, AU and OS, OD, OU

N.B. oculus dexter, oculus sinister, oculus

uterque; auris dextra, auris sinistra, auris

utraque

s c

10

s c

ante

post

sine

cum

male

female

11

12

Physicians written direction for dispensing

or administering a medication for a
patient
Must be written in a specific format

Rx: prescription

Dispensation: name, strength and

amount
Signa: patient instructions

13

: medication
Disp.: dispensing instructions
Sig.: patient instructions
14

Mortar and Pestle

L. recipe receive, take

15

cheirourgia, diaita,
pharmakon
(pharmac/o)
Material

foodstuff (wine, gruel),

parts of plants, parts of
animals, minerals

Simple vs. Compound

Dioscorides (1st century AD), De
materia medica
16

theria, wild beast

Mithradates VI (132-63 BC),
King of Pontus in Asia Minor
Mithradatism

Galens (129-210 AD)

theriac
Ingredients
Experimentation
Galenicals

Medieval Panacea
17

aq.
cap.
tab.
bol.
ung.
lot.,
supp.
gtt.
en.

(L. aqua, water), water

(L. capsula, little box), capsule
(L. tabula, little table) tablet
(L. bolus, fr. Gr. bolos, lump)
(L. unguentum) ointment
lotion
(L. suppositorium), suppository
(L. gutta, drop), drop
(Gr. enema, clyster) enema

18

Parenteral

IM
ID
IV
SC, SQ, Sub-Q

SL
PV
PR
p.o.
top.
19

Parenteral

IM Intramuscular
ID Intradermal
IV Intravenous
SC, SQ, Sub-Q Subcutaneous

SL sublingual
PV per vaginam
PR per rectum
p.o. per os
top. - topical
20

21

Clysters
Suppository
Uterine Fumigation
Hypodermic?

22

ii tab po q6h p.r.n. pain

vi supp. PR q2d noc.
ix tab t.i.d. p.c.

23

I or i = 1
V or v = 5
X or x = 10
L or l = 50
C or c = 100
D or d = 500
M or m = 1000
Subtraction rule:
IV = 4, IX = 9, XL = 40, XC = 90, CD = 400, CM = 900
949 = DCCCCXXXXVIIII = CMXLIX

24

25

26

Here is wisdom. Let him who has

understanding calculate the number of the
beast, for it is the number of a man: His
number is 666. (Rev.13:18-NKJV)

27