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The Medical Record 4

abbriviations and symbols

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
BRP bathroom privilages
CP chest pain
° degree or hour
DC, D/C discontinue or discharge
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