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HLHS 101 Ch2

Introduction to Health Records Abbreviations

TermDefinition
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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