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)
QRS
At bedtime (quaque hora smoni)
(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