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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. Many abbreviations are based on the Latin translation. In those cases, the Latin version follows in parenthesis:

a.c. — (ante cibum) 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 be for ad lib activities

B.i.d. (bis in die) — Twice a day

BM — Bowel movement

BMI — Body mass index

BP — Blood pressure

Bx — Biopsy

C&S — Culture and sensitivity, a test done to detect infection

CBC — Complete blood (cell) count

C.C .— Chief complaint, the patient’s main concern

CXR — Chest X-ray

D/C or DC — Discontinue or discharge, for example, a doctor will D/C a drug. Or, the doctor might DC a patient from the hospital.

DNR — Do not resuscitate

DX — Diagnosis

ETOH — Alcohol intake history, often recorded as part of a patient’s history

H&P — History and physical exam

h.d. — (hora decubitus) At bedtime, as in taking a medicine at bedtime

H/O or h/o — History of a past illness or medical problem that occurred

HA — Headache

HTN — Hypertension or high blood pressure

LBP — Low back pain

NPO — (nihil per os) Nothing by mouth, for example, if a patient is about to have surgery, he or she usually needs to avoid food and beverages for a period

p.c. — (post cibum) After a meal

p.o.— (per os) By mouth

p.r.n.— (pro renata) Periodically as needed, for example, take a pain medication only when you have pain

q.i.d. — (quarter in die) four times a day

R.B.C. — Red blood cell

R/O — Rule out, doctors often rule out various possible diagnoses when determining the correct diagnosis

SOB — Shortness of breath

t.i.d. — (ter in die) Three times a day

URI — Upper respiratory infection, such as sinusitis or a common cold

U/S — Ultrasound

VS — Vital signs, such as temperature, blood pressure, and pulse

WBC — White blood cell