Abbreviation | Meaning/Explanation |
H & P | History and Physical - documentation of patient history and physical examination findings |
Hx | History - record of subjective information regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits |
subjective information | information obtained from the patient including his or her personal perceptions |
CC | chief complaint |
c/o | complains of - patients description of what brought him/her to the doctor/hospital; it is usually brief and is often documented in the patient's own words indicated with quotes |
HPI (PI) | History of present illness (Present illness) - amplification of the chief complain recording details of duration and severity of the condition (how long the patient has had the complaint and how bad it is) |
Sx | symptom - subjective evidence (the the patient) that indicates an abnormality |
PMH (PH) | Past Medical History (Past History) - a record of information about the patient's past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies |
UCHD | usual childhood diseases |
NKA | no known allergies |
NKDA | no known drug allergies |
FH | Family History - state of health of immediate family members - A&W = alive and well, L&W = living and well |
SH | Social history - recreational interests, hobbies and used of tobacco and drugs |
OH | Occupational history - work habits that may involve work-related risks |
ROS (SR) | review of systems (systems review) - documentation of the patients response to questions organized by a head-to-toe review of the function of all body systems |
objective information | facts and observations noted |
PE (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 accommodation |
WNL | within normal limits |
Dx | Diagnosis |
IMP | Impression |
A | Assessment - identification of a disease or dondition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests ad diagnostic procedures |
R/o | Rule Out - used to indicate a differeential diagnosis when one or more diagnoses are suspect each possible diagnosis is outlined and either verified or eliminated after further testing is performed |
P | Plan aka recommendation or disposition - outline of the treatment plan designeed to remedy the patient's condition, which includes instructions to the patient, orders for medications, diagnostic testsm or therapies |