Common Charting Terms and Medical Abbreviations

Question 0

Objective

Answer 0

Physical observations

Question 1

Subjective

Answer 1

Anything about the patient

Question 2

Assessment

Answer 2

Diagnosis

Question 3

Plan

Answer 3

Treatment

Question 4

acute

Answer 4

Severe symptoms, over a short time

Question 5

benign

Answer 5

Mild; noncancerous tumor

Question 6

chronic

Answer 6

Develops slowly over time

Question 7

degeneration

Answer 7

Gradual deterioration of the body function over time

Question 8

diagnosis

Answer 8

A physicians determination of the disease based on findings

Question 9

etiology

Answer 9

Cause of the disease

Question 10

exacerbation

Answer 10

Increase in severity

Question 11

febrile

Answer 11

Having an elevated temperature

Question 12

gross

Answer 12

Visible to the naked eye

Question 13

idiopathic

Answer 13

No clear cause

Question 14

localized

Answer 14

Confined to one area

Question 15

malignant

Answer 15

Harmful, cancerous tumor

Question 16

marked

Answer 16

Important, note-worthy

Question 17

morbidity

Answer 17

State or presence of disease

Question 18

mortality

Answer 18

Death

Question 19

prognosis

Answer 19

Prediction of outcome

Question 20

progressive

Answer 20

Continuing severity

Question 21

prophylaxis

Answer 21

Measures that prevent

Question 22

recurrent

Answer 22

Happening repeatedly

Question 23

systemic

Answer 23

Throughout the body

Question 24

unremarkable

Answer 24

Unimportant

Question 25

inhalation

Answer 25

Vapor or gas inhaled that has entered the blood stream

Question 26

oral

Answer 26

Drug taken by mouth to get to the blood stream

Question 27

rectal

Answer 27

Drug in form of liquid that is inserted into the blood stream

Question 28

sublingual

Answer 28

Drug placed under the tounge to dissolve in the mouth

Question 29

topical

Answer 29

Drugs applied to a certain area

Question 30

transdermal

Answer 30

patch: drug that is absorbed through the skin

Question 31

parenteral

Answer 31

``` "Injected: Intradermal: within the skin Intramuscular: within the muscle Itravenous: into the vein Subcutaneous: just under the skin" ```

Question 32

A

Answer 32

Assesment/ Analysis

Question 33

ADL

Answer 33

Activities of daily living

Question 34

BP

Answer 34

Blood pressure

Question 35

CC

Answer 35

Chief complaint

Question 36

c/o

Answer 36

Complaint of

Question 37

CP

Answer 37

Chest pain

Question 38

D/C

Answer 38

Discontinue

Question 39

⬇️

Answer 39

Decrease/ decreasing

Question 40

Dx

Answer 40

Diagnosis

Question 41

<-o

Answer 41

Male

Question 42

t | O

Answer 42

Female

Question 43

H&P

Answer 43

History and physical

Question 44

Ht

Answer 44

Height

Question 45

Hx

Answer 45

Personal medical history

Question 46

ICU

Answer 46

Intensive care unit

Question 47

⬆️

Answer 47

Increase/ increasing

Question 48

IP

Answer 48

Inpatient

Question 49

L *in a circle*

Answer 49

Left

Question 50

NKA

Answer 50

No known allergies

Question 51

NKDA

Answer 51

No known drug allergies

Question 52

O *slashed*

Answer 52

None

Question 53

OP

Answer 53

Outpatient

Question 54

OR

Answer 54

Operating room

Question 55

P

Answer 55

Pulse

Question 56

PE

Answer 56

Physical examination

Question 57

PI

Answer 57

Present illness

Question 58

postop

Answer 58

Recovery room

Question 59

preop

Answer 59

Preoperating area

Question 60

pt

Answer 60

Patient

Question 61

Px

Answer 61

Physical examination

Question 62

R

Answer 62

Respirations

Question 63

R *in circle*

Answer 63

Right

Question 64

R/O

Answer 64

Rule out

Question 65

ROM

Answer 65

Range of motion

Question 66

ROS

Answer 66

Review of symptoms

Question 67

SOB

Answer 67

Shortness of breath

Question 68

S

Answer 68

Signs

Question 69

Sx

Answer 69

Symptoms

Question 70

T

Answer 70

Temp

Question 71

Tx

Answer 71

Treatment

Question 72

VS

Answer 72

Vital signs

Question 73

WNL

Answer 73

Within normal limits

Question 74

Wt.

Answer 74

Weight

Question 75

_ | a

Answer 75

Before

Question 76

B *in circle*

Answer 76

Bilateral

Question 77

b.i.d.

Answer 77

Twice a day

Question 78

_ | c

Answer 78

With

Question 79

d.

Answer 79

Day

Question 80

h.

Answer 80

Hour

Question 81

_ | p

Answer 81

After

Question 82

_ | p.c.

Answer 82

After meals

Question 83

p.o.

Answer 83

By mouth

Question 84

p.r.n

Answer 84

As needed

Question 85

q.

Answer 85

Each or every

Question 86

q.d.

Answer 86

Every day

Question 87

q.h.

Answer 87

Every hour

Question 88

q.i.d.

Answer 88

4 times a day

Question 89

Rx

Answer 89

Prescription

Question 90

stat.

Answer 90

Immediately

Question 91

t.i.d.

Answer 91

Three times a day

Question 92

_ | s

Answer 92

Without

Question 93

wk

Answer 93

Week

Question 94

yr

Answer 94

Year

Question 95

_ | x

Answer 95

Times or for