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A
assessment
A&W L&W
alive and well, living and well
CC
Chief compliant
c/o
complains of
Dx
diagnosis
FH
family history
HEENT
head,ear, eyes, nose and throat
H&P
history and physical
HPI and PI
history of present illness
Hx
History
IMP
impression
NAD
no acute distress
NKDA
No known drug allergies
O
objective info
OH
occupational history
P
Plan
PE;Px
physical examination
PERRLA
pupils equal, round, and reactive to light and accommodation
PH; PMH
past history: past medical history
R/o
rule out
ROS; SR
Review of systems; systems review
S
subjective info
SH
social history
Sx
symptom
UCHD
usual childhood diseases
WNL
within normal limits
CCU
coronary (cardiac) care unit
ECU
emergency care unit
ER
emergency room
ICU
Intensive care unit
IP
Inpatient
OP
outpatient
OR
operating room
PACU
postanesthesia care unit
PAR
postanesthesia recovery
post-op
postoperative
RTC
Return to clinic
RTO
return to office
BRP
bathroom priviledge’
CP
chest pain
DC and D/C
Discharge; discontinue
ETOH
ethyl alcohol
L
left
R
right
m
murmur
Pt
patient
RRR
Regular rate and rhythm
SOB
shortness of breath
Tr
Treatment
Tx
treatment; traction
VS
vital signs
T
temperature
P
Pulse
R
respiration
BP
Blood pressure
Ht
height
Wt
weight
WDWN
Well-developed and well-nourished
y/o or y.o.
year old
#
number or pound; if before a numeral ( if after the numeral, it means pound the other way its a number)
C
celsius/ centigrade
F
Fahrenheit
degree circle
degree or hour
arrow up
increased
arrow down
decreased
circle with a slash on top
none; negative
cc
cubic centimeter
fl oz
fluid ounce
gr
grain
gt
drop
gtt
drops
oz
ounce
lb or #
pound; equal to 16 ounces
qt
quart; equal to 16 ounces
a
before
a.c
before meals
a.m.
before noon
b.i.d.
twice a day
d
day
h
hour
h.s.
at the hour of sleep
noc
night
p
after
p.c.
after meals
p.m.
after noon
p.r.n
as needed
q
every
q.d.
every day
qh
every hour
q2h
every 2 hour
q.i.d
four times a day
qod
every other day
STAT
immediately
t.i.d
3 times a day
wk
week
yr
year
AD
right ear
AU
both ears
c with line one top
with
NPO
nothing by mouth