Medical Records Management



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O


observation and examination

O&E

observed

obsd

obstruct, obstruction

obst

occasional

occ, occas

occlusal

O

occlusal radiograph

OR

oculus dexter – right eye

OD

oculus sinister – left eye

OS

office visit

OV

ointment

oint, ung

Old Tuberculin

OT

once a day

id

on examination

O/E

one-half

ss

opening

opg

ophthalmology, ophthalmoscope

Oph, Ophth

opposite

opp

optimal

opt

oral contraceptive

OC

oral contraceptive pills

OCP

Oral Glucose Tolerance Test

OGTT

Oral Poliovirus vaccine, live, trivalent

OPV

organization

org

oriented

Orx

Orthodox Union

OU

osteo myelitis

osteo

other

O, o

Otitis Externa

OE

Otitis Media

OM

otoscope

oto

ova and parasites

O&P

oxygen

O, O2

Oxytocin Challenge Test

OCT

P

pack per day

ppd

pair

pr

palatal

P

palpable

palp

panoramics

PAN

Papanicolaou smear

pap

Papillary

Pap.

Para-aminobenzoid acid

PABA

Para-aminosalicyclic acid

PAS

Parathyroid hormone

PH

parent visitor

PV

parity

PARA

partial thromboplastin time

PTT, ptt

parts per million

ppm

past family and social history

PFSH

past history

PH

past medical history

PMH

paternal grandfather/grandmother

PGF, PGM

pathologist

path

patient complains of

pt ℅

patient, patients

Pat, pt, pts

pediatrician

PED

pediatrics

Peds

Pelvic Inflammatory Disease

PID

penicillin

PCN, pen

per high density field

/hdf

per low density field

/ldf

percussion and auscultation

P&A

perforation

perf

periapicals

PA

perimeter

perim

Period late, abnormal bleeding; Abdominal pains, pain with intercourse; Infection, STD, abnormal discharge; Not feeling well, fever, chills; String missing, shorter or longer

PAINS

periodic

per

peripheral

periph

permanent

perm

permanent teeth

1-32

Pertussis vaccine

P

Pervasive Development Disorder

PDD

pharmacy

pharm

Phenylketonuria

PKU

phone order

PO

phosphate

phos, HPO4

phosphorus

P

Pneumocystis carinii pneumonia

PCP

pneumothorax

Pnx

point of entry

POE

Poliomyelitis

polio

Polycystic kidney disease

PKD

Polycystic Ovarian Syndrome

PCOS

Polymerase chain reaction

PCR

Polysaccharide-ribitol-phosphate vaccine

PRP

Positive Pregnancy Test

PPT

positive pressure breathing

PPB

possible

poss

post-exposure prophylaxis

PEP

post nasal drip

PND

posterior

post

posterior/anterior

P/A

postpartum

P.P., PP

postprandial

PP

Postprandial Blood Sugar

PPBS

potassium

K, K+

potassium chloride

KCL

Potassium hydroxide

KOH

Prausnitz-kűstner test

PK test

Pregnancy Induced Hypertension

PIH

pregnancy, pregnant

Pg, preg

Pregnancy Test Education Materials

PTEM

Premature Rupture of Membranes

PROM

premenstrual tension

PMT

prenatal

PN

pre-pregnancy weight

PPW

prescription

Rx

present illness

PI

Presumptive Eligibility

PE

Preventative Medicine

PM

prevention, preventive, previous

prev

previous menstrual period

PMP

Primary Care Physician

PCP

primipara

primip

private medical doctor

PMD

probable, problem

prob

Progestin-only contraceptive pills

POPs

prognosis

Px

progress

progr

Propionic Acidemia

PA

Prostrate specific antigen

PSA

Protease inhibitors

PI

protein

Prot

Protein bound iodine

PBI

Protein Energy Malnutrition

PEM

Prothrombin time

proTime, PT

proximal

prox

psychiatry, psychology

psy, psych

Public Health Nurse

PHN

pulmonary

pul, pulm

pulmonary embolism

PE

pulse

P

pulse and respiration

P & R

pupils equal and react to light

PERL

pupils equal, round, reactive to light and accommodation

PERRLA

pupils equally round and reactive to light

PERRL

purified chick embryo cell

PCEC

purified protein derivative (tuberculin)

PPD

Pyrazinamide

PZA

Pyridoxine

Vitamin B6, B6

Q

quadrant

quad

quality control

QC

Quality Improvement Section

QIS

QuantiFERON-TB Gold In-Tube test®

QFT-GIT

quantitative

quant

quantity not sufficient

QNS

quantity sufficient

qs

Quinolone-resistant Neisseria gonorrhoeae

QRNG

R

Rabies Immune globulin

RIG

Rabies vaccine, adsorbed

RVA

radium

Ra

range of motion, rupture of membranes

ROM

rapid eye movement

REM

Rapid plasma reagent (test), Rapid Plasma Regain

RPR

rate

R, r

rate and rhythm

R&R

reaction

react

ready to feed

RTF

recommendation

recc

recommended dietary allowance

RDA

Recurrent vulvovaginal candidiasis

RVVC

red blood cells

RBC

reflex

refl

refuse(s) medical assistance

RMA

Registered Dietician

RD

Registered Nurse

RN

Registered Therapist

RT

regular rate and rhythm

RRR

respiratory rate

RR

related, relative

rel

related to

r/t

release of information

ROI

Report of Verified Case Tuberculosis

RVCT

residue

res

Respiration

R

Respiratory Distress Syndrome

RDS

resuscitation

resc

return to clinic

rtc, RTC

reverse, review

rev

review of systems

ROS

Rhesus (blood factor)

Rh

riboflavin

Vitamin B2, B2

Ribonucleic acid

RNA

rifabutin

RFB

rifampin

RIF

Rifapentine

RPT

right

D, R, rt

right arm

RA

right deltoid

RD

right eye

RE

right leg

RL

right lower lobe

RLL

right to left

R-L, R/L

right upper leg

RUL

right upper lobe

RUL

risk management

RM

Rocky Mountain Spotted Fever

RMSF

roentgenogram

X-ray

rule out

R/O, r/o

rupture

rupt

S

Salicylic acid

SA

Sanofi Pasteur

SP

Saquinavir

SAQ

science

sci

screen, ask, validate, evaluate/educate

SAVE

second, secondary

sec, 2˚

second hand smoke

SHS

seizure

Sz

self breast examination

SBE

self monitoring blood glucose

SMBG

self testicular exam

STE

sensitivity

sens

sequence

seq

Serologic Test for Syphilis

STS

Serous Otitis Media

SOM

Serum glutamicoxaloacetic transaminase

SGOT

Severe Acute Respiratory Syndrome

SARS

Severe Combined Immunodeficiency

SCID

sexual assault

SA

Sexual Assault Medical Forensic Exam

SAFE

Sexual Assault Nurse Examiner

SANE

Sexual Maturity Rating

SMR

Sexually Transmissible Infection

STI

Sexually Transmitted Disease

STD

Short-chain acyl-CoA dehydrogenase deficiency

SCAD

shortness of breath

SOB

shortness of breath on exertion

SOBE

shoulder

shld

sibling

sib

sickle cell trait

AS, A/S

sickle-cell hemoglobin

HbS

side effects

S/E

signal

sig

signature

sign.

signs and symptoms

S/S

Silver Nitrate

AgNO3

simultaneously

simul

slight

sl

small

sm

small for dates

SFD

small for gestational age

SGA

social history

SH

social worker

SW

sodium

Na

Sodium Bicarbonate

NaHCO3

Sodium chloride

NaCl

son

S

South Eastern National Tuberculosis Center

SNTC

space

sp

specific gravity

sp gr

specimen

spec

spontaneous

spont

Spontaneous abortion

SAB, spon AB

Squamous Intraepithelial Lesions

SIL

standard of care

SOC

standard operating procedures

SOP

staphylococcus

staph

status post

s/p

Stavudine

d4t

Steroidal Anti-Inflammatory Drugs

SAID

stillborn

stb

stimulation

stim

straight

st

Strategic National Stockpike

SNS

streptococcus

strep

streptomycin

SM

structure

struct

Study of Tamixofen and Raloxifene

STAR

subcutaneous, subcutaneously

SQ, subcu, SC

Subjective, Objective, Assessment and Plan

SOAP

substance

subst

Sudden Infant Death Syndrome

SIDS

sulfate

SO4

sulfur

S

sulfuric acid

H2SO4

sunlight protection factor

SPF

superior, supervision

supr

surgery

surg, Sx

symmetrical

sym

symptoms

Sx, symp

syndrome

syn

synthetic

synth

syphilis

syph

syringe

syr

T

tablet

tab

Tachycardia

tachy

TB skin test

TST

telephone call

t.c.

telephone order

TO

temperature

T

temperature, Pulse, Respiration

TPR

term birth, live child

TBLC

terminal

term

Tetanus antitoxin

TAT

Tetanus immune globulin

TIG

Tetanus toxoid

TT

Tetracycline

TC

the same

id

therapeutic abortion

TAB

therapeutic lifestyle changes

TLC

therapeutic, therapy

ther

Thiamin

Vitamin B1, B1

thigh

fem

three times a day

tid

three times a night

tin

three times a week

tiwk

through

per

Thyroid Stimulating Hormone

TSH

Thyroxine

T4

to be taken 3x a day

tds

tolerance, tolerate

tol

too numerous to count

TNTC

Toxic Shock Syndrome

TSS

toxic, toxicity, toxicology

tox

Toxoplasmic encephalitis

TE

Toxoplasmosis, Other, Rubella, Cytomeglovirus, Herpes simplex (titer)

TORCH

trachea, tracheotomy

trach

Transformation Zone

TZ

Transient Ischemic Attack

TIA

transverse

trans

treatment

tr, Tr, Treat, Tx

Trichloroacetic acid

TCA

Trichomonas

Trich

Triglycerides

Trig

tubal ligation

TL

Tubercle Bacillus

TB

Tuberculin Units

TU

Tuberculosis

TB

twice

b

twice a day

bd, bid

twice a week

bi-wk

Tympanic Membrane

TM

Tyrosinemia type-III

TYR-3
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