med record

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Author:
rswartout
ID:
159550
Filename:
med record
Updated:
2012-06-21 10:33:36
Tags:
med record shorthand
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Description:
medical record shorthand
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  1. H & P
    history and physical
  2. CC
    cheif complaint
  3. c/o
    complains of
  4. HPI (PI)
    hostory of present illness (present illness)
  5. PMH (PH)
    past medical history (oast history)
  6. UCHD
    unusual childhood disease
  7. NKA & NKDA
    no known allergies & no known DRUG allergies
  8. FH
    family Hx
  9. SH
    social Hx
  10. OH
    occupational Hx
  11. ROS (SR)
    revies of symptoms (Sx review)
  12. PE (Px)
    physical examination
  13. HEENT
    head, eyes, ears, nose, throat
  14. NAD
    no acute distress, no appreciable disease
  15. PERRLA
    pupils equal, round, and reactive to light and accommodation
  16. WNL
    within normal limits
  17. Dx
    diagnosis
  18. IMP
    impression
  19. A
    assessment
  20. R/O
    rule out
  21. P
    plan
  22. PAR
    postanesthetic recovery
  23. BRP
    bathroom privileges
  24.  CP
    chest pain
  25. ETOH
    ethyl alcohol
  26. RRR
    regular rate and rhythm
  27. SOB
    shortness of breath
  28. VS
    vital signs = temp, pulse, respiration, BP, Ht. Wt, newly added: pain and o2 levels.
  29. Tr
    treatment
  30. Tx
    treatment

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