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HIM abbrevs

purple mod health info management abbrevs

QuestionAnswer
adl activities of daily living
bp blood pressure
CC chief complaint
C.N.S. Central Nervous System
CPE/PE complete physical exam
DOB date of birth
Dx, diag diagnosis
F.Hx family history
N.A.D. no appreciable disease
N.Y.D. not yet diagnosed
P.I. present illness
prog. prognosis
pt. patient
R/O rule out
Rx therapy, prescription
SHx social history
T.P.R., TPR temperature, pulse, respirations
Tx treatment
wt. weight
POMR patient oriented medical record
SOAP subjective objective assessment plan
S/S signs & symptoms
CPP cummulative patient profile
EMR electronic medical record
Created by: MedixMOA
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