Ch. 4 Medical Record
Terms
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copy deck
- #
-
number #2
pound 150#
-
A&W
L&W
-
alive & well
living & well
-
Dx
IMP
A
-
Diagnosis
Impression
Assessment
-
0 -
none or negative
- a.c.
-
before meals
- a.m.
- before noon
- AD
-
right ear
-
ad lib.
-
as desired
- AS
-
left ear
- AU
-
both ears
- b.i.d.
-
twice a day
- BRP
-
bathroom privileges
- c/o
-
complains of
- CC
-
Chief complaint
- CCU
-
Coronary (cardiac) care unit
- CP
-
chest pain
-
DC, D/C
-
discharge, discontinue
- ECU
-
Emergency Care Unit
- ER
-
Emergency Room
- ETOH
-
ethyl alcohol
- FH
-
Family History
- H & P
-
History and Physical
documentation of patient history and physical examination findings
- h.s.
-
at hour of sleep
- HEENT
-
Head Ears Eyes Nose Throat
-
HPI (PI)
-
History of Present Illness (Present illness)
how long and how bad, amplification of chief complaint
- Hx
-
History
Record of subjective info regarding the patient's personal medical history, including past injuries, illnesses, operations, defects, and habits
-
ICU
-
Intensive care unit
- IP
- Inpatient
- NAD
- No acute distress, no appreciable disease
- NKA
- No known allergies
- NKDA
-
No known drug allergies
- noc.
- night
- OH
-
Occupational History
- OP
- outpatient
- OR
-
operating room
- P
- Plan
- p.c.
-
after meals
- p.m.
- after noon
- p.o.
-
by mouth
- p.r.n.
-
as needed
- PACU
- postanesthetic care unit
- PAR
-
post anesthetic recovery
-
PE (Px)
-
Physical examination
- PERRLA
-
pupils equal, round, and reactive to light and accommodation
-
PMH (PH)
-
Past Medical History (Past History)
a record of info about patient's past illnesses
- PR
-
through rectum
- pt
- patient
- PV
-
through vagina
- q
- every
-
q d
-
every day
-
q h
-
every hour
- q.i.d.
- four time a day
- q.o.d.
-
every other day
-
R/O
-
Rule Out
-
ROS (SR)
-
Review of Systems (Systems Review)
- RRR
- regular rate and rhythm
- RTC
- return to clinic
- RTO
-
return to office
- Rx
-
recipe, prescription
- s
- without
- SH
-
Social History
-
Sig:
- label, instruction to the patient
- SOB
-
shortness of breath
- ss
-
one half
- STAT
- immediately
- Sx
- Symptom
- t.i.d.
-
three times a day
- Tr
- treatment
- Tx
-
treatment or traction
- UCHD
-
Usual Childhood Diseases
- VS
-
vital signs
- WDWN
-
well developed and well nourished
- WNL
-
within normal limits