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Ch 4 - Medical Record
Terms
57
Classics
Undergraduate 2
09/03/2009
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Term
H & P
 Definition
History and Physical
Term
Hx
 Definition
History
Term
subjective information
 Definition
information obtained from the patients personal perspective
Term
CC
 Definition
Chief Complain
Term
c/o
 Definition
complains of
Term
HPI
 Definition
History of Present Illness
Term
Sx
 Definition
Symptom
Term
PMH
 Definition
Past Medical History
Term
UCHD
 Definition
usual childhood diseases
Term
NKA
 Definition
no known allergies
Term
NKDA
 Definition
no known drug allergies
Term
FH
 Definition
Family History
Term
SH
 Definition
Social History
Term
OH
 Definition
Occupational History
Term
ROS
 Definition
Review of Systems
Term
objective information
 Definition
facts and observations made
Term
PE
 Definition
Physical Examination
Term
HEENT
 Definition
head, eyes, ears, nose, throat
Term
NAD
 Definition
no acute distress, no appreciable disease
Term
WNL
 Definition
within normal limits
Term
Dx
 Definition
Diagnosis
Term
IMP
 Definition
Impression
Term
A
 Definition
Assessment
Term
R/O
 Definition
Rule Out
Term
P
 Definition
Plan (recommendation or disposition)
Term
CCU
 Definition
coronary care unit
Term
ECU
 Definition
emergency care unit
Term
ER
 Definition
emergency room
Term
ICU
 Definition
intensive care unit
Term
IP
 Definition
inpatient
Term
OP
 Definition
outpatient
Term
OR
 Definition
operating room
Term
PACU
 Definition
post-anesthetic care unit
Term
postop
 Definition
postoperative
Term
preop
 Definition
preoperative
Term
RTC
 Definition
return to clinic
Term
RTO
 Definition
return to office
Term
BRP
 Definition
bathroom privileges
Term
CP
 Definition
chest pain
Term
DC, D/C
 Definition
discharge
Term
ETOH
 Definition
ethyl alcohol
Term
(L)
 Definition
left
Term
(R)
 Definition
right
Term
pt
 Definition
patient
Term
RRR
 Definition
regular rate and rhythm
Term
SOB
 Definition
shortness of breath
Term
Tr
 Definition
treatment
Term
Tx
 Definition
treatment or traction
Term
VS
 Definition
vital signs
Term
T
 Definition
temperature
Term
P
 Definition
pulse
Term
R
 Definition
respiration
Term
BP
 Definition
blood pressure
Term
Ht
 Definition
Height
Term
Wt
 Definition
Weight
Term
WDWN
 Definition
well-developed and well-nourished
Term
y.o.
 Definition
year old
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