Medical Record Abbreviation

Question 1

H & P

Answer 1

history and physical – documentation of patient history and physical examination findings

Question 2

Hx

Answer 2

history– record of subjective information regarding the patients personal medical history, including past injuries, illnesses, operations, defects, and habits

Question 3

subjective information

Answer 3

information obtained from the patient including his or her personal perceptions

Question 4

CC

Answer 4

chief complaint

Question 5

c/o

Answer 5

complaints of– patients description of what brought him or her to the doctor or hospital; it is usually brief and is often documented in the patients own words indicated within quotes (“I feel like I swallowed a stick and it got stuck in my back”)

Question 6

HPI (PI)

Answer 6

history of present illness– amplification of the chief complaint recording details of the duration and severity of the condition (how long the patient has had the complaint and how bad it is)

Example: the patient has had left lower back pain for the past 2 weeks since slipping on a rug and landing on her left side; the pain worsens after sitting upright and any extended period but gradually subsides after lying in a supine position

Question 7

Sx

Answer 7

symptom– subjective evidence from the patient that indicates an abnormality

Question 8

PMH (PH)

Answer 8

Past medical history– record of information about the patient’s past illness starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies

Question 9

UCHD

Answer 9

usual childhood diseases- the patient had usual or commonly contracted illnesses during childhood (measles, chickenpox, mumps)

Question 10

NKA

Answer 10

no known allergies

Question 11

NKDA

Answer 11

no known drug allergies

Question 12

FH

Answer 12

family history- state of health of immediate family members

A&W- alive and well
L&W- living and well
FH: father, age 92, L&W; mother, age 91, died, stroke

Question 13

SH

Answer 13

social history- record of the patients recreational interests, hobbies, and use of tobacco and drugs, including alcohol

SH: plays tennis twice/wk; tobacco–none; alcohol–drinks 1-2 beers per day

Question 14

OH

Answer 14

occupational history- record of work habits that may involve work-related risks

OH: the patient has been employed as a heavy equipment operatory for the past 6 years

Question 15

ROS (SR)

Answer 15

Review of Systems (Systems Review)

a documentation of the patients response to questions organized by a head-to-toe review of the function of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned)

Question 16

objective information

Answer 16

facts and observations noted

Question 17

PE (Px)

Answer 17

physical examination – documentation of a physical examination of patient, including notation of positive and negative objective findings

Question 18

HEENT

Answer 18

head, eyes, ears, nose, throat

Question 19

NAD

Answer 19

no acute distress, no appreciable disease

Question 20

PERRLA

Answer 20

pupils equal, round, and reactive to light and accommodation

Question 21

WNL

Answer 21

within normal limits

Question 22

Dx

Answer 22

diagnosis

Question 23

IMP

Answer 23

impression

Question 24

A

Answer 24

assessment– identification of a disease or condition after evaluation of the patients history, symptoms, signs, and results of laboratory tests and diagnostic procedures

Question 25

R/O

Answer 25

rule out– used to indicate a differential diagnosis when one or more diagnoses are suspect; each possible diagnosis is outlined and either verified or eliminated after further testing is performed

Diagnosis: R/O pancreatitis, R/O gastroenteritis
this indicates that either of these two diagnoses is suspected and further testing is required to verify or eliminate one or both possibilities

Question 26

P

Answer 26

Plan (also referred to as recommendation or disposition) – outline of the treatment plan designed to remedy the patients condition, which includes instructions to the patient, orders for medications, diagnostic tests, or therapies