CNA/PCT Terminology - Assessment & Documentation

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Last updated 4:22 PM on 6/9/26
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31 Terms

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A&O

alert and oriented

2
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CC

chief complaint

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c/o

complains of

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DOA

dead on arrival

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DOB

date of birth

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Dx

diagnosis

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F/U

follow-up

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FHx

family history

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H/O

history of

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H&P

history and physical

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Hx

history

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ID

identification

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LOC

level of consciousness

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LOS

length of stay

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MOI

mechanism of injury

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PMH

past medical history

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POD

postoperative day

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pt

patient

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R/O

rule out

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s/p

status post

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S/S

signs and symptoms

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Tx

treatment

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UTD

up to date

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VS

vital signs

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w/o

without

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w/u

work up

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WNL

within normal limits

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y/o

years old

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OPQRST

onset, provocation, quality, radiation, severity, time

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SBAR

situation, background, assessment, recommendation

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SOAP

subjective, objective, assessment, plan