Health Care Records Flashcards
HPI, PI
history of present illness,
present illness
bid
twice a day
Tr
treatment
RRR
regular rate and rhythm
PERRLA
pupils equal, round, and reactive to light and accommodation
#
Pound
IP
inpatient
CC
chief complaint
po
per os (by mouth)
CP
chest pain
P
pulse
pp
after meals
OD
right eye
ac
before meals
g or gm
gram
IMP
impression
dr
dram
OU
both eyes
VS
vital signs
NKA,
NKDA
no known allergies,
no known drug allergies
SOB
shortness of breath
OP
outpatient
L&W
living and well
L
Left or Liter
per
by or through
PAR
post anesthetic recovery
RTO
return to office
Dx
Diagnosis
A
Assessment
qs
quantity sufficient
RTC
return to clinic
R/O
rule out
x
times or for
qod
every other day
OH
occupational history
ROS, SR
review of systems,
systems review
q
every
PR
through rectum
qns
quantity not sufficient
Tx
treatment or traction
Sx
symptom
CCU
coronary (cardiac) care unit
gt
drop
AS
left ear
OS
left eye
qh
every hour
Ht
Height
pc
after meals
qd
Every day
tid
three times a day
DC, D/C
discharge, discontinue
WNL
within normal limits
ad lib
as desired
P
Plan (recommendation, disposition)
S
subjective information
d
day
H & P
history and physical
ETOH
ethyl alcohol
AU
Both ears
BRP
bathroom privileges
AD
right ear
pt
patient
WDWN
well-developed and well-nourished
HEENT
head, eyes, ears, nose, throat
F
Fahrenheit
ECU
emergency care unit
cu mm
cubic millimeter
R
right
NAD
no acute distress
aq
water
gtt
drops
PE, Px
physical examination
C
Celsius, centigrade
UCHD
usual childhood diseases
qid
four times a day
O
objective information
y/o, y.o.
year old
cc
cubic centimeter
A & W
alive and well
SH
social history
prn
as needed
gr
grain
R
respiration
PH, PMH
past history,
past medical history
Sig
label; instruction to the patient
c/o
complains of
FH
family history
PV
through vagina
h
hour
Hx
history
hs
at hour of sleep (bedtime)
