Medical Record Practice
Using the following combination list of medical terms and abbreviations to translate the radiology report written below. Terms that would be translated by the medical transcriptionist for the patient’s chart are underlined.
Pt.
16 y/o
male arrived @ 1645
by ambulance in ER
with c/o
pain in Lt
. distal
leg p
falling in a skiing accident which occurred around 1620
. EMS
reported finding pt. in
supine position
with skis unattached. Upon exam, edema
and redness noted at site of
pain. PMS
preformed with P&S
intact, however patient denied being able to move
leg.
EMS
splinted leg, o2 @ 4 l/m
. VS
normal. ER
Dr. ordered A/P
and Lateral x-ray of left
tibia/fibula. X-ray revealed spiral fx
of left distal
tibia/fibula consistent with pt. MOI
.
Report released stat to ER Dr
. contacted ortho Dr
.
A/P- anterior/posterior (front to back)
@ - at
c/o - complaints of
distal - point far away from the point of reference or lower end of an extremity
Dr. – doctor
Edema - swelling
EMS - emergency medical service
ER- emergency room
l/m - liters per minute
lt.- left
MOI - mechanism of injury
O2 - oxygen
Ortho - orthopedic (bone doctor)
P - after
PMS - pulse motor (movement) and sensory (feeling)
P&S - Pulse and Sensory
Pt - patient
Spiral fx - spiral fracture
Supine - lying on back
VS - vital signs
1620 - military time for 4:20 pm
1645 - military time for 4:45 pm
Copyright © Texas Education Agency, 2017. All rights reserved. 1
of 1
