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The Medical Record 4
abbriviations and symbols
| Question | Answer |
|---|---|
| H&P | history and physical |
| OH | occupational history |
| Hx | history |
| ROS | review of systems |
| CC | chief complaint |
| PE | physical exam |
| c/o | complains of |
| HEENT | head, eyes, ears, nose, throat |
| HPI | history of present illness |
| NAD | no acute distress |
| Sx | symptom |
| PERRLA | pupils equal, round and reactive to light and accomodation |
| PMH | past medical history |
| WNL | within normal limits |
| UCHD | usual childhood diseases |
| Dx | diagnosis |
| NKA | no known allergies |
| NKMA | no known medication allergies |
| NKDA | no known drug allergies |
| FH | family history |
| SH | social history |
| IMP | impression |
| A | assessment |
| R/O | rule out |
| P | plan |
| SOAP | subjective, objective, assessment, plan |
| CCU | coronary care unit |
| T | temperature |
| ER | emergency room |
| P | pulse |
| ICU | intensive care unit |
| R | respiration |
| IP | inpatient |
| BP | blood pressure |
| OP | outpatient |
| Ht | height |
| OR | operating room |
| Wt | weight |
| post-op | after surgery |
| yo | year old |
| pre-op | before surgery |
| # | number or pound |
| RTC | return to clinic |
| ♀ | female |
| ♂ | male |
| BRP | bathroom privilages |
| CP | chest pain |
| ° | degree or hour |
| DC, D/C | discontinue or discharge |
| ↑ | increased |
| ↓ | decreased |
| ETOH | ethyl alcohol |
| Tr | treatment or trace |
| Tx | treatment or traction |
| VS | vital signs |
| gr | grain |
| gt | drop |
| gtt | drops |
| dr | dram 1/8 ounce |
| c with line over it | with |
| s with line over it | without |
Created by:
jhlcc
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