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A & O
Alert and oriented
NICU
Neonatal Intensive Care Unit
AC
Before meals (ante cibum)
NKDA
No known drug allergies
(B)
Bilateral
NPO
Nothing by mouth (nil per os)
BID
Twice a day (bis in die)
OR
Operating Room
BMI
Body mass index
PACU
Post-anesthesia Care Unit
BP
Blood pressure
PC
After meals (post cibum)
CC
Chief complaint
PERRLA
Pupils equal, round, and reactive to light and accommodation
c/o
Complains of
PE
Physical exam
CTA
Clear to auscultation
PMH/PMHx
Past medical history
d/c
Discontinue
PO
By mouth (per os)
DC
Discharge (leave medical facility)
Post-op
Post-operative Care
DNR
Do not resuscitate
PR
Rectal (per rectum)
Dx
Diagnosis
Pre-op
Pre-operative Care
DDx
Differential diagnosis
PRN
As needed (per re nata)
ER
Emergency Room
pt
Patient
f/u
Follow up
QD
Once a day (quaque die)
FH/FHx
Family history
QHS
At bedtime (quaque hora smoni)
h/o
History of
(R)
Right
H & P
History and physical
ROS
Review of symptoms
HPI
History of present illness
RR
Respiratory rate
HR
Heart rate
RRR
Regular rate and rhythm (heart)
Ht
Height
Rx
Therapy or prescription
i/o
Intake and output (fluids)
SC
Subcutaneous
ICU
Intensive Care Unit
SH/SHx
Social history
IM
Intramuscular
T
Temperature
IV
Intravenous
TID
Three times a day (ter in die)
(L)
Left
Tx
Treatment
L & D
Labor and Delivery
VS
Vital signs
N & V
Nausea and vomiting
WDWN
Well developed, well nourished
NAD
No acute distress
Wt
Weight