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135 Cards in this Set
- Front
- Back
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H & P
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History and Physical
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Hx
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History
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CC
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Chief Complaint
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c/o
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complains of
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HPI (PI)
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History of Present Illness (Present Illness)
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Sx
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symptom
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PMH (PH)
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Past Medical History (Past History)
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UCHD
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usual childhood diseases
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NKA
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no known allergies
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NKDA
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no known drug allergies
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FH
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Family History
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SH
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Social History
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OH
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Occupational History
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ROS (SR)
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Review of Systems (Systems Review)
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PE (Px)
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Physical Examination
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HEENT
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head, eyes, ears, nose, throat
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NAD
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no acute distress, no appreciable disease
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PERRLA
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pupuls equal, round, and reactive to light and accomodation
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WNL
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within normal limits
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Dx
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Diagnosis
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IMP
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Impression
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A
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Assessment
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R/O
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Rule Out
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P
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Plan (also referred to as recommendation or disposition)
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CCU
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coronary (cardiac) care unit
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ECU
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emergency care unit
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ER
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emergency room
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ICU
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intensive care unit
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IP
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inpatient (a registered bed patient)
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OP
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outpatient
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OR
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operating room
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PACU
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postanesthetic care unit
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PAR
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postanesthetic recovery
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post-op/postop
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postoperative (after surgery)
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pre-op/preop
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preoperative (before surgery)
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RTC
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return to clinic
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RTO
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return to office
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BRP
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bathroom privileges
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CP
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chest pain
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DC, D/C
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discharge, discontinue
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ETOH
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ethyl alcohol
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L - circled
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left
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R - circled
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right
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pt
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patient
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RRR
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regular rate and rhythm
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SOB
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shortness of breath
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Tr
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treatment
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Tx
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treatment or traction
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VS
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vital signs
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T
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temperature
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P
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pulse
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R
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respiration
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BP
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blood pressure
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Ht
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height
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Wt
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weight
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WDWN
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well-developed and well-nourished
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y.o.
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year old
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#
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number if before numeral; pound if after numeral
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♀
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female
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♂
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male
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°
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degree or hour
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↑
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increased
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↓
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decreased
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Ө
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none or negative
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O
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standing
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O
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sitting
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O---
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lying
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cc
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cubic centimeter (1cc = 1mL)
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cm
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centimeter (2.5cm = 1in)
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g, gm
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gram
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kg
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kilogram (1kg = 2.2lb)
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L
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liter
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mg
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milligram
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ml, mL
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milliliter
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mm
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millimeter
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cu mm
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cubic millimeter
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fl oz
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fluid ounce
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gr
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grain
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gt
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drop
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gtt
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drops
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dr
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dram (1/8 ounce)
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oz
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ounce
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lb, #
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pound (16 ounces)
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qt
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quart (32 ounces)
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_
a |
before
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a.c.
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before meals
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a.m.
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before noon
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b.i.d.
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twice a day
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d
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day
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h
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hour
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h.s.
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at hour of sleep (bedtime)
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noc.
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night
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_
p |
after
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p.c.
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after meals
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p.m.
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after noon
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p.r.n.
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as needed
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q
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every
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q d
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every day
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q h
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every hour
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q 2 h
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every 2 hours
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q.i.d.
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four times a day
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q.o.d.
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every other day
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STAT
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immediately
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t.i.d.
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three times a day
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wk
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week
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yr
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year
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AD
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right ear
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AS
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left ear
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AU
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both ears
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ad lib.
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as desired
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amt
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amount
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aq
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water
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B - circled
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bilateral
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C
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Celsius, centigrade
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_
c |
with
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F
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Fahrenheit
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m - circle
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murmur
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NPO
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nothing by mouth
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OD
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right eye
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OS
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left eye
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OU
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both eyes
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per
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by or through
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p.o.
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by mouth
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PR
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through rectum
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PV
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through vagina
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q.n.s.
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quantity not sufficient
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q.s.
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quantity sufficient
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Rx
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recipe; prescription
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Sig:
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label; instruction to the patient
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_
s |
without
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__
ss |
one-half
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w.a.
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while awake
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x
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times or for
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>
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greater than
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<
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less than
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