Common Abbreviations in Patient History Documentation

0.0(0)
studied byStudied by 0 people
learnLearn
examPractice Test
spaced repetitionSpaced Repetition
heart puzzleMatch
flashcardsFlashcards
Card Sorting

1/82

encourage image

There's no tags or description

Looks like no tags are added yet.

Study Analytics
Name
Mastery
Learn
Test
Matching
Spaced

No study sessions yet.

83 Terms

1
New cards

Pt, pt ,pt.

Patient

2
New cards

y.o.

Year-old

3
New cards

M

Male

4
New cards

F

Female

5
New cards

W

White

6
New cards

B

Black, African-American

7
New cards

H

Hispanic

8
New cards

L (often circled)

Left

9
New cards

R (often circled)

Right

10
New cards

LMP

Last menstrual period

11
New cards

OB

Obstetrics, obstetrical, obstetrician

12
New cards

Gyne, Gyn

Gynecologic, gynecological, gynecology, gynecologist

13
New cards

IUD

Intrauterine device

14
New cards

BCPs

Birth control pills

15
New cards

GPA System

Gravidus, L. pregnancy

16
New cards

G

Gravidus, L. pregnancy

17
New cards

P

Paritus, L. parturition, birth

18
New cards

A, Ab

Abortus, L. Abortion, which includes miscarriages

19
New cards

e.g. G4P3A1

4 Pregnancies, 3 births, 1 abortion or miscarriage

20
New cards

G0

Nulligravida (n), nulligravidous (adj.) - patient has never been pregnant

21
New cards

P0

Nullipara (n.), nulliparaous (adj.) - patient has never given birth

22
New cards

G1

Primigravida (n.), primigravidous (adj.) - first pregnancy

23
New cards

P1

Prmipara, primip, (n) primiparous (adj.) - first birth

24
New cards

h/o

History of

25
New cards

c/o

Complains of

26
New cards

s/p

Status post, after - usually used following an event like surgical procedure, injury or illness

27
New cards

D

Day, days

28
New cards

Wk, wk. (wks)

Week (weeks)

29
New cards

Mo, mo. (mos, mos.)

Month (months)

30
New cards

Yr, yr. (yrs, yrs.)

Year (years)

31
New cards

Hr, hr., (hrs, hrs.)

Hour (hours)

32
New cards

𝑐̅

With

33
New cards

𝑠̅

Without

34
New cards

𝑝̅

After

35
New cards

Δ

Change

36
New cards

Ø

None

37
New cards

N/A

Not applicable

38
New cards

Rx

Prescription

39
New cards

Sig

Directions

40
New cards

BID, b.i.d

Bis in die, twice a day

41
New cards

TID, t.i.d

Ter in die, three times a day

42
New cards

QID, q.i.d

Quarter in die, four times a day

43
New cards

Q

Quaque, every, each, per

44
New cards

QD

Every day, write out daily to avoid confusion

45
New cards

QOD

Every other day write out every other day to avoid confusion

46
New cards

Prn

Pro re nata, as needed

47
New cards

PO

Per os, by mouth

48
New cards

NPO

Nil per os, nothing by mouth

49
New cards

NKA

No known allergies

50
New cards

NKDA

No known drug allergies

51
New cards

OTC

Over-the-counter medications

52
New cards

EtOH

Alcohol

53
New cards

Tx

Treatment or therapy

54
New cards

Hx

History

55
New cards

Dx

Diagnosis

56
New cards

S/S

Symptoms and Signs (or signs and symptoms)

57
New cards

R/O

Rule out

58
New cards

SOB

Shortness of breath

59
New cards

DOB

Date of birth

60
New cards

DOE

Dyspnea on exertion

61
New cards

DOA

Dead on arrival

62
New cards

DNR

Do not resuscitate

63
New cards

HA

Headache

64
New cards

MI

Myocardial infarction

65
New cards

CHF

Congestive heart failure

66
New cards

HTN

Hypertension

67
New cards

COPD

Chronic obstructive pulmonary disease

68
New cards

GERD

Gastroesophageal reflux disease

69
New cards

T1D

Type 1 Diabetes

70
New cards

T2D

Type 2 Diabetes

71
New cards

NAD

No acute distress

72
New cards

STD(s)

Sexual transmitted disease(s)

73
New cards

GI

Gastrointestinal

74
New cards

GU

Genitourinary

75
New cards

RUQ

Right upper quadrant (of abdomen)

76
New cards

LUQ

Left upper quadrant

77
New cards

RLQ

Right lower quadrant

78
New cards

LLQ

Left lower quadrant

79
New cards

N/V

Nausea/vomiting

80
New cards

N/V/D

Nausea/vomiting/diarrhea

81
New cards

URI

Upper respiratory infection

82
New cards

UTI

Urinary tract infection

83
New cards

WNL

Within normal limits