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Chapter 4 med record

Medical Record Abbreviations

QuestionAnswer
H & P History and Physical
Hx History
CC Chief Complaint
c/o Complains of
HPI History of Present Illness
Sx Symptoms
PMH Past Medical History
UCHD Usual Childhood Diseases
NKA No Known Allergies
NKDA No Known Drug Allergies
FH Family History
SH Social History
OH Occupational History
ROS Review of Systems
PE Physical Exam
HEENT Head, Eyes, Ears, Nose, Throat
NAD No Accute Distress
PERRLA Pupils equal, round, and reactive to light and accomodation
WNL Within normal limitsWithin Normal Limits
Dx Diagnosis
IMP Impression
A Assessment
R/O Rule/Out
Created by: LCC
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