Patient Preparation terms

70 glossary entries from the Patient Preparation domain of the CPT test plan. Try free Patient Preparation practice questions.

24-hour urineAll urine for 24 hours: flush the first morning void and note the time, then save every void through the next…
A1CHemoglobin A1C (HbA1c): shows how high blood sugar has run, on average, over roughly the last 2 to 3 months; no…
ABNAdvance Beneficiary Notice of Non-coverage: Medicare form given before a test Medicare may not pay for, so the patient…
advance directiveA legal document, such as a living will or health care power of attorney, stating care wishes for when the patient…
arteriovenous fistulaA surgical joining of an artery and a vein, usually in the arm, for hemodialysis. That arm is never used for…
arteriovenous graftA soft tube joining an artery and a vein under the skin for hemodialysis access; that arm is not used for draws.
basal stateThe body early in the morning after an overnight fast and rest, before exercise; many reference values come from…
BPBlood pressure, written systolic over diastolic in mm Hg. An arm with a dialysis fistula or graft is never used for a…
CBCComplete blood count: hematology panel giving the numbers of each blood cell type plus hemoglobin and hematocrit…
cholesterolA fatty substance in blood measured in a lipid panel. Fast only when the order says so, usually for 9 to 12 hours.
clean-catch midstream specimenUrine collected after cleaning the urethral area: start voiding into the toilet, catch the middle portion in a sterile…
copaymentA fixed dollar amount the patient pays for a service, such as $25 per visit, as opposed to coinsurance, a percentage.
CPOEComputerized provider order entry: the provider types test orders directly into the electronic record instead of…
deliriumSudden, often reversible confusion. A delirious patient may not give reliable identifiers, so a nurse or guardian…
diabetes mellitusLong-term condition in which glucose stays too high because the body makes little insulin, responds poorly to it, or…
diurnal variationNormal rise and fall of some substances over the day; cortisol, for example, is highest in the morning and much lower…
DMDiabetes mellitus. A patient who takes diabetes medicine and is fasting for a draw can develop low blood sugar; watch…
dorsal hand veinsVeins on the back of the hand, the next site to assess when the antecubital veins cannot be used.
edemaSwelling from excess fluid in the tissues. An edematous (swollen) arm is not used for venipuncture; choose another site.
EHRElectronic health record: digital chart built to move with the patient between providers and settings; orders are…
empathyRecognizing and naming the patient's feeling while keeping the focus on them ("That sounds stressful"), unlike…
EMRElectronic medical record: the computerized chart one practice or facility keeps for its own patients.
ESRDEnd-stage renal disease: kidney failure treated with dialysis or a transplant. A dialysis fistula or graft arm is…
express consentConsent the patient states directly, aloud or in writing; required for invasive or riskier procedures.
fasting blood glucoseGlucose measured after at least 8 hours with no food or drink other than water.
fasting specimenBlood drawn after no food or drink except water for the ordered time, at least 8 hours for fasting glucose. Document a…
first morning voidUrine passed on waking, usually the most concentrated sample of the day; preferred for urine pregnancy tests.
FITFecal immunochemical test: home stool kit whose antibodies react only with human hemoglobin, so hidden bleeding can be…
FOBTFecal occult blood test: checks stool for blood too small to see; the patient usually collects the samples at home…
gender identityA person's inner sense of their own gender, which may differ from the sex recorded at birth; ask the patient's name…
half-lifeThe time for a drug's blood level to fall by half; it is one reason peak and trough levels must be drawn at the…
HDLHigh-density lipoprotein, the "good" cholesterol, reported in a lipid (cholesterol) panel.
hormoneA chemical messenger carried in the blood. Some hormones, such as cortisol, rise and fall over the day, so timed draws…
hypertensionBlood pressure that stays above the normal range over time; also called high blood pressure.
ICD-10-CMThe diagnosis code set. The ordering provider supplies the code that supports a test's medical necessity; a…
implicit biasUnconscious associations, for example about race, gender, age or weight, that can shape judgments and care.
implied consentConsent shown by actions, such as holding out an arm after the draw is explained; accepted only for routine, low-risk…
informed consentAgreement given after the patient understands a procedure's purpose, risks, benefits and alternatives; needed for…
INRInternational normalized ratio: the prothrombin time put on a standard scale so results agree between labs; used to…
insulinPancreatic hormone that moves glucose from the blood into cells, lowering blood glucose. Insulin without enough food…
IVIntravenous: into a vein. Draw from the other arm when an IV is infusing, because IV fluid or medicine can alter the…
latex allergyAllergy to natural rubber latex. Use latex-free gloves, tourniquets and supplies for an allergic patient.
LDLLow-density lipoprotein, the "bad" cholesterol, reported in a lipid panel. Fast before the draw only when the order…
lymphedemaSwelling from blocked lymph drainage, which can follow lymph node removal for breast cancer; do not draw from the…
mastectomySurgical removal of a breast. Draw from the opposite arm; if both sides are affected, the provider decides which site…
MedicaidGovernment health coverage for many low-income people, funded jointly by federal and state money; who qualifies and…
MRNMedical record number: a number the facility assigns to one patient; acceptable as one of the two required identifiers.
NPINational Provider Identifier: a permanent 10-digit number assigned to each health care provider and used on claims and…
NPONothing by mouth (Latin nil per os): the patient may not eat or drink. Check the order before offering a drink or…
O&POva and parasites: a stool test for parasites and their eggs. Nothing else, such as urine, water or toilet paper, may…
occult bloodBlood present in amounts too small to see, as in stool; found with a fecal occult blood test or a fecal immunochemical…
Patient Care PartnershipAmerican Hospital Association plain-language guide to hospital patients' rights and expectations, such as safe care…
patient identifiersDetails unique to the patient, such as full name, birth date or medical record number; use at least two, never a room…
peak levelDrug level drawn when the concentration is highest, for example about 30 minutes after an IV antibiotic infusion ends…
PTProthrombin time: a clotting test collected in a sodium citrate (light blue-top) tube and reported with the INR to…
PTTPartial thromboplastin time: a coagulation test, drawn in a light blue-top sodium citrate tube, commonly ordered to…
requisitionThe test order, paper or electronic: patient name and identifiers, sex and age or birth date, ordering provider…
SBARSituation, Background, Assessment, Recommendation: a structured way to report a patient problem to a nurse or provider.
sputumThick mucus coughed up from deep in the lungs, not saliva. The patient rinses with water, then coughs it into a…
STATPriority meaning "now" (Latin statim). Collect and send a STAT specimen without delay, ahead of routine work; a timed…
TDMTherapeutic drug monitoring: blood tests that measure a medicine's level, drawn at ordered times relative to the dose.
teach-backAsking the patient to explain instructions in their own words to confirm understanding; a nod or "yes" is not proof.
therapeutic drug monitoringMeasuring a medicine's blood level to keep it safe and effective. Record the drug, the time of the last dose and the…
timed specimenA specimen collected at an ordered clock time or interval, such as a morning cortisol or a drug level; record the…
TPNTotal parenteral nutrition: complete nutrition infused into a vein. As with any infusion, do not draw from that arm…
triglyceridesBlood fats measured in a lipid panel. Eating shortly before the draw raises them, which is why fasting may be ordered.
trough levelDrug level drawn when the concentration is lowest: at the end of the dosing interval, just before the next dose.
urethraThe tube that carries urine from the bladder out of the body; the area around its opening is cleaned before a…
UTIUrinary tract infection. A clean-catch midstream urine specimen is collected for the urine culture that diagnoses it.
wrong blood in tubeWBIT: a tube labeled with one patient's identity that holds another patient's blood, caused by identification or…