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111 Cards in this Set
- Front
- Back
CC
|
chief complaint
|
|
OH
|
occupational Hx
|
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PR
|
through rectum
|
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BRP
|
bathroom privileges
|
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PACU
|
postanesthetic care unit
|
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PH
|
past medical Hx
|
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D/C
|
discharge or discontinue
|
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Sig:
|
label, patient instruction
|
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ER
|
emergency room
|
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ICU
|
intensive care unit
|
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R/O
|
rule out
|
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NPO
|
nothing by mouth
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L&W
|
living and well
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BP
|
blood pressure
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AU
|
both ears
|
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Sx
|
symptoms
|
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VS
|
vital signs
|
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ROS
|
review of systems
|
|
pt
|
patient
|
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OD
|
right eye
|
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Sub-Q
|
subcutaneous - under the skin
|
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H&P
|
Hx and physical
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TX
|
treatment or traction
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Dx
|
diagnosis
|
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HPI
|
Hx of present illenss
|
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febrile
|
relating to fever - elevated fever
|
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syndrome
|
set of symptoms characteristic of disease or condition
|
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chronic
|
developing slowly, lasting
|
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remission
|
period where symptoms or signs stop or abate
|
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etiology
|
study of cause of a disease
|
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malignant
|
cancerous
|
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prognosis
|
probable outcome of a disease
|
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Dx
|
name of disease based on Hx, exam, and testing
|
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Exacerbation
|
increase in severity with aggravation of symptoms
|
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localized
|
limited to a definite are or part
|
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Po
|
route of oral medications
|
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OR
|
place for surgery
|
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Ad lib
|
as desired
|
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SOAP
|
progress note
|
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#
|
pound
|
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p.r.n.
|
as needed
|
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parenteral
|
by injection
|
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pre-op
|
before surgery
|
|
stat
|
immediately
|
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OH example
|
works as a secruity officer
|
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UCHD (usual childhood diseases) example
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had all commonly contracted childhood diseases
|
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HPI example
|
pain in the lower back for 2 weeks, worse @ night
|
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PE (physical exam) example
|
lungs: clear
heart: regular rate and rhythm |
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CC example
|
lower back pain
|
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SH (social Hx)
|
quit smoking 2 years ago, drinks alcohol socially
|
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FH (family Hx) example
|
father, age 88, L&W
mother, age 78, died, stroke |
|
P (plan) example
|
advised to lower salt intake
|
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A (assessment) example
|
Ex: tonsillitis
|
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NKA (no known allergies)
|
no reaction to any previously administered drug
|
|
using ionizing radiation
|
computed tomography, radiology, radionuclide organ imaging
|
|
computed tomography
|
3D x-rays
|
|
magnetic resonance imaging (MRI)
|
radio waves
|
|
radiology
|
standard x-rays
|
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radionuclide organ imaging
|
gamma rays
|
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sonography
|
ultrasound waves
|
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a (line above) (ante)
|
before
|
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a.c. (ante cibum)
|
before meals
|
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a.m. (ante meridiem)
|
before noon
|
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b.i.d. (bis in die)
|
twice a day
|
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d
|
day
|
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h (hora)
|
hour
|
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h.s. (hora somni)
|
at hour of sleep (bedtime)
|
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noc. (noctis)
|
night
|
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p (line over) (post)
|
after
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p.c. (post cibum)
|
after meals
|
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p.m. (post meridiem)
|
after noon
|
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p.r.n. (pro re nata)
|
as needed
|
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q (quaque)
|
every
|
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q d (quaque die)
|
every day
|
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q h (quaque hora)
|
every hour
|
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q 2 h
|
every 2 hours
|
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q.i.d. (quater in die)
|
four times a day
|
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q.o.d. (quaque altera die)
|
every other day
|
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STAT
|
immediately
|
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t.i.d. (ter in die)
|
three times a day
|
|
wk
|
week
|
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yr
|
year
|
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AD (auris dextra)
|
right ear
|
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AS (auris sinistra)
|
left ear
|
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AU (aures unita)
|
both ears
|
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ad lib. (ad libitum)
|
as desired
|
|
amt
|
amount
|
|
aq (aqua)
|
water
|
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B (encircled)
|
bilateral
|
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C
|
celsius, centigrade
|
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c (line over) (cum)
|
with
|
|
F
|
Fahrenheit
|
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m (encircled)
|
murmur
|
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NPO (non per os)
|
nothing by mouth
|
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OD (oculus dexter)
|
right eye
|
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OS (oculus sinister)
|
left eye
|
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OU (oculus unitas)
|
both eyes
|
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per
|
by or through
|
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p.o. (per os)
|
by mouth
|
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PR (per rectum)
|
through rectum
|
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PV (per vagina)
|
through vagina
|
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q.n.s.
|
quantity not sufficient
|
|
q.s.
|
quantity sufficent
|
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Rx
|
recipe; prescription
|
|
Sig: (signa)
|
label; instruction to the patient
|
|
s (line over) (sine)
|
without
|
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ss (line over) (semis)
|
one-half
|
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w.a.
|
while awake
|
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x
|
times or for [e.g., x 6 (six times), x 2 d (for 2 days)]
|
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>
|
greater than
|
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<
|
less than
|