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Med. Record Abbrev.
Medical Terminology by Marjorie Canfield, Chapter 4
| Question | Answer |
|---|---|
| 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 |
| ꜛ | increased |
| ꜜ | decreased |
| 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
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