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HLHS 101 Ch2
Introduction to Health Records Abbreviations
| Term | Definition |
|---|---|
| CCU | Coronary Care Unit |
| ECU | Emergency Care Unit |
| ER | Emergency Room |
| ED | Emergency Department |
| ICU | Intensive Care Unit |
| PICU | Pediatric Intensive Care Unit |
| NICU | Neonatal Intensive Care Unit |
| SICU | Surgical Intensive Care Unit |
| PACU | Post-Anesthesia Care Unit |
| L & D | Labor & Delivery |
| OR | Operating Room |
| Post-Op | after surgery |
| Pre-Op | before surgery |
| VS | Vital Signs |
| T | Temperature |
| BP | Blood Pressure |
| HR | Heart Rate |
| RR | Respiratory Rate |
| Ht | Height |
| Wt | Weight |
| BMI | Body Mass Index (measurement of body fat based on height and weight) |
| I/O | Intake/Output [the amount of fluids a patient has taken in (by IV or mouth) and the produced (usually just urine output)] |
| Dx | Diagnosis |
| DDx | Differential Diagnosis |
| Tx | Treatment |
| Rx | Prescription |
| H & P | History & Physical |
| Hx | history |
| CC | Chief Complaint (the main reason for the visit) |
| HPI | History of Present Illness (the story of the symptoms) |
| ROS | Review Of Symptoms (anything else not directly related to the chief complaint) |
| PMHx | Past Medical History |
| FHx | Family History |
| PE | Physical Exam |
| Pt | Patient |
| y/o | Years Old |
| h/o | History Of |
| PCP | Primary Care Provider |
| f/u | Follow Up |
| SOB | Shortness Of Breath |
| PERRLA | Pupils are Equal, Round, and Reactive to Light and Accommodation |
| NAD | No Acute Distress (the patient does not display any intense symptoms) |
| RRR | Regular Rate and Rhythm (description of a normal heart on exam) |
| CTA | Clear To Auscultation (description of normal sounding lungs) |
| WDWN | Well Developed, Well Nourished (the patient is grown or has grown appropriately and does not appear to be malnourished) |
| A & O | Alert & Oriented (the patient can answer questions and is aware of what is going on) |
| WNL | Within Normal Limits |
| NOS | Not Otherwise Specified (catch-all for diagnoses that don't quite fit any specific cause) |
| NEC | Not Elsewhere Classified (catch-all for diagnoses that don't quite fit any specific cause) |
| PO | Per Os (by mouth) |
| NPO | Nil Per Os (nothing by mouth) |
| PR | Per Rectum (anal) |
| IM | IntraMuscular |
| SC | SubCutaneous (under the skin) |
| IV | IntraVenous |
| CVL | Central Venous Line |
| PICC | Peripherally Inserted Centeral Catheter |
| Sig | instructions short for "signa" from Latin for LABEL |
| ad lib | as desired |
| BID | twice daily (Latin: two in a day) |
| TID | three times daily (Latin: three in a day) |
| QD | daily (Latin: each day) (now prohibited in many healthcare settings) |
| QID | four times daily (Latin: four in a day) (now prohibited in many healthcare settings) |
| QHS | at night (Latin: each night at the hour of sleep) |
| AC | before meals (Latin: before food) |
| PC | after meals (Latin: after food) |
| prn | as needed (Latin: as the need arises) |
Created by:
choover29
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