Common Medical Abbreviations in Clinical Notes
The abbreviations below appear constantly in H&Ps, progress notes, and discharge summaries, grouped by where in the note you will meet them. The trainer's abbreviation toggle switches its phrase corpus between spelled-out and abbreviated forms using these conventions.
Practice note phrases with shorthand Same phrases, spelled out
Preset links open the trainer with those settings already applied; you can change them afterward.
History and presentation
| Abbreviation | Meaning |
|---|---|
| CC, HPI, ROS | chief complaint, history of present illness, review of systems |
| PMH, PSH, FHx, SHx | past medical, past surgical, family, and social history |
| NKDA | no known drug allergies |
| 65-y/o | 65-year-old |
| c/o, w/, w/o | complains of, with, without |
| SOB, CP, N/V, LOC | shortness of breath, chest pain, nausea and vomiting, loss of consciousness |
| s/p, 2/2, c/b | status post, secondary to, complicated by |
| Hx of, r/o | history of, rule out |
Exam and data
| Abbreviation | Meaning |
|---|---|
| VS, Tmax, BP, HR, RR, SpO2 | vital signs, maximum temperature, blood pressure, heart rate, respiratory rate, oxygen saturation |
| RA, NC, HFNC | room air, nasal cannula, high-flow nasal cannula |
| NAD, A&Ox3, WNL | no acute distress, alert and oriented to person, place, and time, within normal limits |
| RRR, CTAB | regular rate and rhythm, clear to auscultation bilaterally |
| RLQ, LUQ, RUL, LLL | right lower quadrant and left upper quadrant (abdomen); right upper lobe and left lower lobe (lungs) |
| CN, LE, UE, ROM | cranial nerves, lower and upper extremity, range of motion |
| I/O, UOP | intake and output, urine output |
| CXR, CT, US, EKG, TTE | chest X-ray, computed tomography, ultrasound, electrocardiogram, transthoracic echocardiogram |
For what each lab panel contains and how labs are written in notes, see lab abbreviations and fishbone diagrams.
Assessment and plan
| Abbreviation | Meaning |
|---|---|
| c/f, ddx | concerning for, differential diagnosis |
| HD#, POD# | hospital day, postoperative day |
| f/u, PCP | follow up, primary care physician |
| po, iv, im, subQ, PR | by mouth, intravenous, intramuscular, subcutaneous, per rectum |
| BID, TID, QID, qHS, q6h, PRN | twice, three times, four times daily; at bedtime; every 6 hours; as needed |
| NPO, ADAT | nothing by mouth, advance diet as tolerated |
| Ppx, DVT ppx, GI ppx | prophylaxis; deep vein thrombosis prophylaxis; gastrointestinal (stress ulcer) prophylaxis |
| PT/OT, SNF, DME | physical and occupational therapy, skilled nursing facility, durable medical equipment |
| Dispo, AMA | disposition, against medical advice |
| Full code, DNR/DNI | code status: full code (all resuscitation measures); do not resuscitate, do not intubate |
For the Latin behind BID, qHS, PRN, and the other dosing abbreviations, plus routes, units, and drip rates, see medication abbreviations.
Common conditions
These appear in every section: HTN (hypertension), DM2 (type 2 diabetes mellitus), CAD (coronary artery disease), CHF (congestive heart failure) and HFrEF (heart failure with reduced ejection fraction), AFib (atrial fibrillation), COPD (chronic obstructive pulmonary disease), CKD (chronic kidney disease), AKI (acute kidney injury), UTI (urinary tract infection), PE (pulmonary embolism), DVT (deep vein thrombosis), MI (myocardial infarction), GERD (gastroesophageal reflux disease), and OSA (obstructive sleep apnea).
Abbreviations you should not use
The Joint Commission's official do-not-use list, which most hospitals enforce, bans U and u (write unit), IU (write international unit), QD and QOD (write daily and every other day), trailing zeros (5 mg, never 5.0 mg), missing leading zeros (0.5 mg, never .5 mg), and MS, MSO4, and MgSO4 (write morphine sulfate or magnesium sulfate). Many institutions add their own, commonly including cc (cubic centimeters; write mL), µg (micrograms; write mcg), and > or < in orders. ISMP's longer list of error-prone abbreviations, with what to write instead, is on the medication abbreviations page. When a practice phrase in the trainer uses qd, treat it as reading practice for older charts and type daily in your own notes.
For how these fit into the structure of a note, see clinical documentation typing.