Scribe Shorthand Dictionary

TIME

+

yes, positive

-

no, negative

#d (/a)

# days (ago)

#h

# hours

#min

# minutes

#mo

# months

#w

# weeks

#y

# years

#yf

# year old female

#ym

# year old male

am

morning

epd

episode

l/n, ln

last night

l/w

last week

nt or pm

night, evening

ons

onset

pr

prior

pt

patient

PTA

prior to arrival

td

today

tmr

tomorrow

wk🡹

wake up

yst

yesterday

NOTE

1°

primary

2°

secondary

alg

allergies

alg rxn

allergic reaction

dx

diagnosis/diagnostics

fhx

family history

hx

history

cav

level 5 caveat

M:

medications

PMHx

past medical history

PSHx

past surgical history

rx

prescription

SHx

social history

sx

symptoms

tx

treatment

UTD

up-to-date

DESCRIPTION OF PAIN

🡹

increasing/worsening

🡹🡹

gradualy increasing/worsening

➔

radiating/to

occ

occasional

+/- rel

yes/no relief of pain

ac

acute

b/l

bilateral

c/o

complains of

chr

chronic

dsc

discomfort

exc

exacerbate

impr

improved

intm

intermittent

L

left

lw

lower

m

mild

M

moderate

p (#/10)

pain (rated # out of 10)

prs

pressure

R

right

rad

radiating

rslv

resolved

rep

reports

S

severe

shp

sharp

spf

superficial

sud

suddenly

s/o

sudden onset

t

tenderness

thk

thick/thickness

up

upper

Δ

change

SYMPTOMS

abdp

abdominal pain

abn

abnormal

amb

ambulate/ambulatory

bl

blood

bls

blister

b/b/dysf

bowel or bladder dysfunction

brn

burn

br

breath, breathing

br

bruise

cng

congestion

cg

cough

ch

chills

cp

chest pain

crmp

cramping

dp

diaphoresis

du

dysuria

dz

dizziness

ery

erythema

f

fever

f 100

fever of 100 degrees

T max 101

maximum temp of 101

frq

urinary frequency

GI bl

GI bleeding

ha

headache

hcz

hematochezia