Medical Records Abbreviations

Vocabulary flashcards covering common medical abbreviations and their meanings.

A & O

Alert and oriented

AC

Before meals (ante cibum)

(B)

Bilateral

BID

Twice a day (bis in die)

BMI

Body mass index

BP

Blood pressure

CC

Chief complaint

c/o

Complains of

CTA

Clear to auscultation

d/c

Discontinue

DC

Discharge (leave medical facility)

DNR

Do not resuscitate

Dx

Diagnosis

DDx

Differential diagnosis

ER

Emergency Room

f/u

Follow up

FH/FHx

Family history

h/o

History of

H & P

History and physical

HPI

History of present illness

HR

Heart rate

Ht

Height

i/o

Intake and output (fluids)

ICU

Intensive Care Unit

IM

Intramuscular

IV

Intravenous

(L)

Left

L & D

Labor and Delivery

N & V

Nausea and vomiting

NAD

No acute distress

NICU

Neonatal Intensive Care Unit

NKDA

No known drug allergies

NPO

Nothing by mouth (nil per os)

OR

Operating Room

PACU

Post-anesthesia Care Unit

PC

After meals (post cibum)

PERRLA

Pupils equal, round, and reactive to light and accommodation

PE

Physical exam

PMH/PMHx

Past medical history

PO

By mouth (per os)

Post-op

Post-operative Care

PR

Rectal (per rectum)

Pre-op

Pre-operative Care

PRN

As needed (per re nata)

pt

Patient

QD

Once a day (quaque die)

QHS

At bedtime (quaque hora somni)

(R)

Right

ROS

Review of symptoms

RR

Respiratory rate

RRR

Regular rate and rhythm (heart)

Rx

Therapy or prescription

SC

Subcutaneous

SH/SHx

Social history

T

Temperature

TID

Three times a day (ter in die)

Tx

Treatment

VS

Vital signs

WDWN

Well developed, well nourished

Wt

Weight