Making Sense of Medical Notes
If you’ve ever tried to read a medical chart, but couldn’t understand the doctor’s shorthand, the following definitions may help:
a.c.—Before meals, as in taking a medicine before meals.
Ad lib—At liberty. For example, a patient may be permitted to move out of bed freely and orders would, therefore, be for ad lib activities.
C&S—Culture and sensitivity, a test performed to detect infection.
CBC—Complete blood count.
CC—Chief complaint, the patient’s main concern.
D/C or DC—Discontinue or discharge. For example, a doctor will D/C a drug. Alternatively, the doctor might DC a patient from the hospital.
DDX—Differential diagnosis, which means a variety of possible diagnoses.
ETOH—Alcohol intake history, often recorded as part of a patient’s history.
H&P—History and physical examination.
h.s.—At bedtime, as in taking a medicine at bedtime.
H/O or h/o—History of a past illness or medical problem that occurred.
IMP—Impression. This is the diagnosis of the patient’s condition by the health care practitioner at that particular date and time.
LBP—Low back pain.
N/V—Nausea or vomiting.
NPO—Nothing by mouth. For example, if a patient is about to undergo a surgical procedure requiring general anesthesia, he or she is usually required to avoid food and beverages before the procedure.
p.r.n.—Periodically as needed. The words mean, for example, that you would take a pain medication only when you have pain.
PERRLA—Pupils equal, round, and reactive to light and accommodation.
R/O—Rule out. Doctors frequently rule out various possible diagnoses when determining the correct diagnosis.
SOB—Shortness of breath.
URI—Upper respiratory infection, such as sinusitis or a common cold.
VSS—Vital signs are stable. This notation means from the standpoint of temperature, blood pressure, and pulse, the patient is doing well.
- Fincannon, Joy, RN, MN
- Hanrahan, Maura, MD