abbreviations used in examination and progress notes Flashcards
1
Q
A
A
assessment
2
Q
A&W
A
alive and well
3
Q
BP
A
blood pressure
4
Q
c (with a bar)
A
with
5
Q
CC
A
chief complaint
6
Q
c/o
A
complaints of
7
Q
CP
A
chest pain
8
Q
d
A
day
9
Q
Dx
A
diagnosis
10
Q
EtOH
A
ethyl alcohol (beverage alcohol)
11
Q
FH
A
family history
12
Q
HEENT
A
head, eyes, ears, nose, and throat
13
Q
H&P
A
history and physical
14
Q
HPI, PI
A
history of present illness, present illness
15
Q
Hx
A
history
16
Q
IMP
A
impression
17
Q
L
A
left
18
Q
L&W
A
living and well
19
Q
NAD
A
no acute distress
20
Q
NKA, NKDA
A
no known allergies, no known drug allergies
21
Q
O
A
objective information
22
Q
OH
A
occupational history
23
Q
P
A
plan (recommendation, disposition); pulse
24
Q
PE, Px
A
physical examination
25
PERRLA
pupils equal, round, and reactive to light and accommodation
26
PH, PMH
past history, past medical history
27
Pt
patient
28
R
respiration
29
R
right
30
RTC
return to clinic
31
R/O
rule out
32
ROS, SR
review of systems, systems review
33
S
subjective information
34
s (with bar)
without
35
SH
social history
36
SOAP
subjective, objective, assessment, plan
37
SOB
shortness of breath
38
STAT, stat
referring to something that should be done immediately
39
Sx
symptom
40
t.i.d.
three times a day
41
UCHD
usual childhood diseases
42
WNL
within normal limits
43
y.o.
year old
44
yr
year
