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Med. Record Abbrev.

Medical Terminology by Marjorie Canfield, Chapter 4

H&P History and Physical
Hx History
CC Chief Complaint
c/o complains of
HPI History of Present Illness
PI Present Illness
Sx symptom
PMH Past Medical History
PH Past 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
SR Systems Review
PE Physical Examination
Px Physical Examination
HEENT head, eyes, ears, nose, throat
NAD no acute distress, no appreciable disease
PERRLA pupils equal, round, and reactive to light and accomodation
WNL within normal limits
Dx Diagnosis
IMP Impression
A Assesment
R/O Rule Out
P Plan, recommendation or disposition
CCU coronary (cardiac) care unit
ECU emergency care unit
ER emergency room
ICU intensive care unit
IP inpatient
OP outpatient
OR operating room
PACU postanesthetic care unit
PAR postanesthetic recovery
post-op/postop postoperative
pre-op/preop preoperative
RTC return to clinic
RTO return to office
BRP bathroom privileges
CP chest pain
DC (error prone) discharge, discontinue (better: spell out)
ETOH ethyl alcohol
L (in a circle) left
R (in a circle) right
pt patient
RRR regular rate and rhythm
SOB shortness of breath
Tr treatment
Tx treatment or traction
VS vital signs
T temperature
P pulse
R respiration
BP blood pressure
Ht height
Wt weight
WDWN well-developed and well-nourished
y.o year old
# number or pound
° degree or hour
circle with a cross female
circle with an arrow male
Ɵ done or negative
lollipop standing
broken lollipop sitting
abandoned lollipop lying
CBC complete blood count
UA urinalysis
CT computed tomography
CAT computed axial tomography
MRI magnetic resonance imaging
MRA magnetic resonance angiography
U/S or US diagnostic ultrasound, sonography
m meter (39.37 inches)
L liter (1.0567 quarts)
g / gm gram
cc (error prone) cubic centimeter (1 cc = 1mL)
cm centimeter (2.5 cm = 1 inch)
kg kilogram (1,000 grams, 2.2 pounds)
mg milligram = one thousandth (0.001) of a gram
ml, mL milliliter = one thousandth (0.001) of a liter
mm millimeter = one thousandth (0.001) of a meter
cu mm cubic millimeter
fl oz fluid ounce
gr grain
gt drop (Latin gutta = drop)
gtt drops (Latin gutta = drop)
dr dram (1/8 ounce)
oz ounce
lb or # pound (16 ounces)
qt quart (32 ounces)
tab tablet
cap capsule
per os by mouth
p.o. by mouth
SL under the tongue
suppos suppository
PV per vagina
PR per rectum
ID intradermal (within the skin)
IM intramuscular (within the muscle)
IV intravenous (within the vein)
Sub-Q subcutaneous (under the skin)
SC (error prone) subcutaneous (under the skin)
SQ (error prone) subcutaneous (under the skin)
q.d. (error prone) every day (better: daily)
q.o.d. (error prone) every other day (better:every other day)
D/C (error prone) discharge, discontinue (better: spell out)
AS (error prone) left ear (better: spell out) auris sinistra
AD (error prone) right ear (better: spell out) auris dextra
AU (error prone) both ears (better: spell out) auris unitas
OS (error prone) left eye (better: spell out) oculus sinister
OD (error prone) right eye (better: spell out) oculus dexter
OU (error prone) both eyes (better: spell out) oculus unitas
‹, › (error prone) less than, greater than (better: spell out)
ā before (ante)
a.c. before meals (ante cibum)
a.m. before noon (ante meridiem)
b.i.d. twice a day (bis in die)
d day
h hour
h.s. (error prone) at hour of sleep (bedtime, hora somni)
noc. night (noctis)
ṗ (line instead of dot) after (post)
p.c. after meals (post cibum)
p.m. after noon (post meridiem)
p.r.n. as needed (pro re nata)
q every (quaque)
q d (error prone) every day (quaque die)
q h every hour (quaque hora)
q 2 h every 2 hours
q.i.d. four times a day (quaque altera die)
q.o.d. (error prone) every other day (quaque altera die)
STAT immediately (statim)
t.i.d. three times a day (ter in die)
wk week
yr year
ad lib. as desired (ad libitum)
amt amount
aq water (aqua)
B (in a circle) bilateral
C Celsius, centigrade
c (with a line on top) with (cum)
F Fahrenheit
m (in a circle) murmur
NPO nothing by mouth
per by or through
q.n.s. quantity not sufficient
q.s. quantity sufficient
Rx recipe, prescription
Sig: label; instructions to the patient (L. signa)
s (with a line on top) without (L. sine)
ss (with a line on top) one-half (L. semis)
w.a. while awake
X times or for
one (modified lowercase Roman numeral)
†† two (modified lowercase Roman numeral)
††† three (modified lowercase Roman numeral)
Created by: mariselafm