abbreviations used in examination and progress notes Flashcards

You may prefer our related Brainscape-certified flashcards:
1
Q

A

A

assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A&W

A

alive and well

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

BP

A

blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

c (with a bar)

A

with

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

CC

A

chief complaint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

c/o

A

complaints of

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

CP

A

chest pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

d

A

day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Dx

A

diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

EtOH

A

ethyl alcohol (beverage alcohol)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

FH

A

family history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

HEENT

A

head, eyes, ears, nose, and throat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

H&P

A

history and physical

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

HPI, PI

A

history of present illness, present illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Hx

A

history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

IMP

A

impression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

L

A

left

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
Q

PERRLA

A

pupils equal, round, and reactive to light and accommodation

26
Q

PH, PMH

A

past history, past medical history

27
Q

Pt

A

patient

28
Q

R

A

respiration

29
Q

R

A

right

30
Q

RTC

A

return to clinic

31
Q

R/O

A

rule out

32
Q

ROS, SR

A

review of systems, systems review

33
Q

S

A

subjective information

34
Q

s (with bar)

A

without

35
Q

SH

A

social history

36
Q

SOAP

A

subjective, objective, assessment, plan

37
Q

SOB

A

shortness of breath

38
Q

STAT, stat

A

referring to something that should be done immediately

39
Q

Sx

A

symptom

40
Q

t.i.d.

A

three times a day

41
Q

UCHD

A

usual childhood diseases

42
Q

WNL

A

within normal limits

43
Q

y.o.

A

year old

44
Q

yr

A

year