Health Care Records Flashcards
(91 cards)
1
Q
HPI, PI
A
history of present illness,
present illness
2
Q
bid
A
twice a day
3
Q
Tr
A
treatment
4
Q
RRR
A
regular rate and rhythm
5
Q
PERRLA
A
pupils equal, round, and reactive to light and accommodation
6
Q
#
A
Pound
7
Q
IP
A
inpatient
8
Q
CC
A
chief complaint
9
Q
po
A
per os (by mouth)
10
Q
CP
A
chest pain
11
Q
P
A
pulse
12
Q
pp
A
after meals
13
Q
OD
A
right eye
14
Q
ac
A
before meals
15
Q
g or gm
A
gram
16
Q
IMP
A
impression
17
Q
dr
A
dram
18
Q
OU
A
both eyes
19
Q
VS
A
vital signs
20
Q
NKA,
NKDA
A
no known allergies,
no known drug allergies
21
Q
SOB
A
shortness of breath
22
Q
OP
A
outpatient
23
Q
L&W
A
living and well
24
Q
L
A
Left or Liter
25
per
by or through
26
PAR
post anesthetic recovery
27
RTO
return to office
28
Dx
Diagnosis
29
A
Assessment
30
qs
quantity sufficient
31
RTC
return to clinic
32
R/O
rule out
33
x
times or for
34
qod
every other day
35
OH
occupational history
36
ROS, SR
review of systems,
| systems review
37
q
every
38
PR
through rectum
39
qns
quantity not sufficient
40
Tx
treatment or traction
41
Sx
symptom
42
CCU
coronary (cardiac) care unit
43
gt
drop
44
AS
left ear
45
OS
left eye
46
qh
every hour
47
Ht
Height
48
pc
after meals
49
qd
Every day
50
tid
three times a day
51
DC, D/C
discharge, discontinue
52
WNL
within normal limits
53
ad lib
as desired
54
P
Plan (recommendation, disposition)
55
S
subjective information
56
d
day
57
H & P
history and physical
58
ETOH
ethyl alcohol
59
AU
Both ears
60
BRP
bathroom privileges
61
AD
right ear
62
pt
patient
63
WDWN
well-developed and well-nourished
64
HEENT
head, eyes, ears, nose, throat
65
F
Fahrenheit
66
ECU
emergency care unit
67
cu mm
cubic millimeter
68
R
right
69
NAD
no acute distress
70
aq
water
71
gtt
drops
72
PE, Px
physical examination
73
C
Celsius, centigrade
74
UCHD
usual childhood diseases
75
qid
four times a day
76
O
objective information
77
y/o, y.o.
year old
78
cc
cubic centimeter
79
A & W
alive and well
80
SH
social history
81
prn
as needed
82
gr
grain
83
R
respiration
84
PH, PMH
past history,
| past medical history
85
Sig
label; instruction to the patient
86
c/o
complains of
87
FH
family history
88
PV
through vagina
89
h
hour
90
Hx
history
91
hs
at hour of sleep (bedtime)
