Commonly Used Abbreviations in Patient History PDF
Document Details
Uploaded by SelectiveHilbert
Southern California University of Health Sciences
Tags
Summary
This document provides a list of commonly used abbreviations in written patient histories. It details various abbreviations for different medical conditions, procedures, and symptoms, along with their corresponding meanings.
Full Transcript
Commonly Used Abbreviations in Written Patient History Abbreviation Meaning Pt, pt ,pt. Patient y.o. Year-old M Male F Female W White B Black, African-Am...
Commonly Used Abbreviations in Written Patient History Abbreviation Meaning Pt, pt ,pt. Patient y.o. Year-old M Male F Female W White B Black, African-American H Hispanic Other Ethnicities Written out L (often circled) Left R (often circled) Right LMP Last menstural period OB Obstetrics, obstetrical, obstetrician Gyne, Gyn Gynecologic, gynecological, gynecology, gynecologist IUD Intrauterine device BCPs Birth control pills GPA System G Gravidus, L. pregnancy P Paritus, L. parturition, birth A, Ab Abortus, L. Abortion, which includes miscarriages e.g. G4P3A1 = 4 Pregnancies, 3 births, 1 abortion or miscarriage G0 Nulligravida (n), nulligravidous (adj.) – patient has never been pregnant P0 Nullipara (n.), nulliparaous (adj.) – patient has never given birth G1 Primigravida (n.), primigravidous (adj.) – first pregnancy P1 Prmipara, primip, (n) primiparous (adj.) – first birth Multigravida, No abbreviation – had multiple pregnancies multigravidous Multipara, multip, No Abbreviation – had multiple births multiparous h/o History of c/o Complains of s/p Status post, after – usually used following an event like surgical procedure, injury or illness e.g.: 6d s/p MI, 1wk s/p appendectomy D Day, days Wk, wk. (wks) Week (weeks) Mo, mo. (mos, Month (months) mos.) Yr, yr. (yrs, yrs.) Year (years) Hr, hr., (hrs, hrs.) Hour (hours) 𝑐̅ With 𝑠̅ Without 𝑝̅ After Δ Change Ø None N/A Not applicable Rx Prescription Sig Directions BID, b.i.d Bis in die, twice a day TID, t.i.d Ter in die, three times a day QID, q.i.d Quarter in die, four times a day Q Quaque, every, each, per QD Every day, write out daily to avoid confusion On JCAHO QOD Every other day write out every other day to avoid confusion forbidden list Prn Pro re nata, as needed PO Per os, by mouth NPO Nil per os, nothing by mouth NKA No known allergies NKDA No known drug allergies OTC Over-the-counter medications EtOH Alcohol Tx Treatment or therapy Hx History Dx Diagnosis S/S Symptoms and Signs (or signs and symptoms) R/O Rule out SOB Shortness of breath DOB Date of birth DOE Dyspnea on exertion DOA Dead on arrival DNR Do not resuscitate HA Headache MI Myocardial infarction CHF Congestive heart failure HTN Hypertension COPD Chronic obstructive pulmonary disease GERD Gastroesophogeal reflux disease T1D Type 1 Diabetes T2D Type 2 Diabetes NAD No acute distress STD(s) Sexual transmitted disease(s) STI(s) Sexual transmitted infection(s) GI Gastrointestinal GU Genitourinary RUQ Right upper quadrant (of abdomen) LUQ Left upper quadrant RLQ Right lower quadrant LLQ Left lower quadrant N/V Nausea/vomiting N/V/D Nausea/vomiting/diarrhea URI Upper respiratory infection UTI Urinary tract infection WNL Within normal limits