Common Acronyms and Clinical Terms | Help Center

Key ideas

Acronyms are common in U.S. notes, but clarity matters more than speed.
Use abbreviations only when they are standard in context and unlikely to be misunderstood.
When learning, write the full term until the abbreviation becomes natural.

History and note structure

CC: Chief complaint. The main reason for the visit, often in the patient's words.
HPI: History of Present Illness. The story of the current problem.
ROS: Review of Systems. Focused symptom review by body system.
PMH: Past medical history.
PSH: Past surgical history.
FH: Family history.
SH: Social history.
Meds: Medications.
All: Allergies in some note formats. Avoid if it could be confused with all.
NKDA: No known drug allergies.
NKA: No known allergies.
Sx: Symptoms or surgery depending on context. Use carefully.
Dx: Diagnosis.
Tx: Treatment.
Rx: Prescription or treatment.
Hx: History.

Vitals and measurements

VS: Vital signs.
T: Temperature.
HR: Heart rate.
BP: Blood pressure.
RR: Respiratory rate.
SpO2: Peripheral oxygen saturation.
BMI: Body mass index.
Wt: Weight.
Ht: Height.
I/O: Intake and output.
UOP: Urine output.
GCS: Glasgow Coma Scale.

General clinical words

Acute: New or short-term, often requiring timely evaluation.
Chronic: Longstanding or persistent.
Subacute: Between acute and chronic in timing.
Acuity: How urgent or severe the clinical situation is.
Etiology: Cause of a disease or symptom.
Pathophysiology: The mechanism by which disease causes abnormal function.
Differential diagnosis: The set of possible diagnoses being considered.
Pertinent positive: A present finding that supports a diagnosis or affects risk.
Pertinent negative: An absent finding that helps argue against a diagnosis or risk.
Red flag: A symptom, sign, or context that suggests danger or need for urgent evaluation.
Disposition: Where the patient goes next after evaluation.
Return precautions: Specific warning signs that should prompt urgent reevaluation.

Assessment and plan

A/P: Assessment and plan.
DDx: Differential diagnosis.
R/O: Rule out. Often used when evaluating a dangerous or possible diagnosis.
W/U: Workup.
Labs: Laboratory tests.
Imaging: Radiology or other image-based diagnostics.
Consult: Request for specialist evaluation or recommendations.
Admit: Place the patient in the hospital as an inpatient or observation patient.
D/C: Discharge or discontinue, depending on context. Use carefully.
F/U: Follow-up.
PRN: As needed.
STAT: Immediately or urgently.

Common body systems

HEENT: Head, eyes, ears, nose, throat.
CV: Cardiovascular.
Pulm: Pulmonary.
GI: Gastrointestinal.
GU: Genitourinary.
MSK: Musculoskeletal.
Neuro: Neurologic.
Psych: Psychiatric.
Derm: Dermatologic or skin-related.
Endo: Endocrine.
Heme: Hematologic.
ID: Infectious disease.

Symptoms and exam abbreviations

SOB: Shortness of breath.
DOE: Dyspnea on exertion.
CP: Chest pain.
N/V: Nausea and vomiting.
N/V/D: Nausea, vomiting, and diarrhea.
Abd pain: Abdominal pain.
HA: Headache.
LOC: Loss of consciousness or level of consciousness depending on context.
AMS: Altered mental status.
A&O: Alert and oriented.
NAD: No acute distress.
CTA: Clear to auscultation, or CT angiography depending on context.
RRR: Regular rate and rhythm.
NTND: Nontender, nondistended.
CVA tenderness: Costovertebral angle tenderness, often relevant to renal or urinary pathology.

Diagnostic tests

CBC: Complete blood count.
CMP: Comprehensive metabolic panel.
BMP: Basic metabolic panel.
LFTs: Liver function tests or liver chemistries.
UA: Urinalysis.
UPT: Urine pregnancy test.
ECG/EKG: Electrocardiogram.
CXR: Chest X-ray.
CT: Computed tomography.
MRI: Magnetic resonance imaging.
US: Ultrasound in clinical notes. Can also mean United States in prose.
Troponin: Cardiac biomarker used in evaluation of myocardial injury.
D-dimer: Blood test sometimes used in thromboembolic disease evaluation in appropriate risk contexts.
Lactate: Marker that may support evaluation of shock, sepsis, hypoperfusion, or other metabolic stress.

Medication and dosing terms

PO: By mouth.
IV: Intravenous.
IM: Intramuscular.
SQ/SC: Subcutaneous.
BID: Twice daily.
TID: Three times daily.
QID: Four times daily.
QHS: At bedtime.
QAM: Every morning.
QD: Daily, but many institutions discourage it because it can be misread.
NPO: Nothing by mouth.
OTC: Over the counter.
Contraindication: A reason a medication, test, or treatment should not be used.
Adverse effect: An unwanted or harmful effect of a medication or intervention.

Acronym safety

Acronyms save time only when the reader understands them the same way you do. Some abbreviations are ambiguous across specialties or institutions. In a learning note, clarity wins.

Avoid abbreviations that can mean two different things in the same context.
Spell out high-risk medication instructions.
Use standard disease names when the acronym may be unfamiliar.
Do not use informal shorthand from text messaging.
When in doubt, write the full term.

History and note structure

Chief complaint. The main reason for the visit, often in the patient's words.

HPI

History of Present Illness. The story of the current problem.

ROS

Review of Systems. Focused symptom review by body system.

PMH

Past medical history.

PSH

Past surgical history.

Family history.

Social history.

Meds

Medications.

All

Allergies in some note formats. Avoid if it could be confused with all.

NKDA

No known drug allergies.

NKA

No known allergies.

Symptoms or surgery depending on context. Use carefully.

Diagnosis.

Treatment.

Prescription or treatment.

History.

General clinical words

Acute

New or short-term, often requiring timely evaluation.

Chronic

Longstanding or persistent.

Subacute

Between acute and chronic in timing.

Acuity

How urgent or severe the clinical situation is.

Etiology

Cause of a disease or symptom.

Pathophysiology

The mechanism by which disease causes abnormal function.

Differential diagnosis

The set of possible diagnoses being considered.

Pertinent positive

A present finding that supports a diagnosis or affects risk.

Pertinent negative

An absent finding that helps argue against a diagnosis or risk.

Red flag

A symptom, sign, or context that suggests danger or need for urgent evaluation.

Disposition

Where the patient goes next after evaluation.

Return precautions

Specific warning signs that should prompt urgent reevaluation.

Assessment and plan

A/P

Assessment and plan.

DDx

Differential diagnosis.

R/O

Rule out. Often used when evaluating a dangerous or possible diagnosis.

W/U

Workup.

Labs

Laboratory tests.

Imaging

Radiology or other image-based diagnostics.

Consult

Request for specialist evaluation or recommendations.

Admit

Place the patient in the hospital as an inpatient or observation patient.

D/C

Discharge or discontinue, depending on context. Use carefully.

F/U

Follow-up.

PRN

As needed.

STAT

Immediately or urgently.

Symptoms and exam abbreviations

SOB

Shortness of breath.

DOE

Dyspnea on exertion.

Chest pain.

N/V

Nausea and vomiting.

N/V/D

Nausea, vomiting, and diarrhea.

Abd pain

Abdominal pain.

Headache.

LOC

Loss of consciousness or level of consciousness depending on context.

AMS

Altered mental status.

A&O

Alert and oriented.

NAD

No acute distress.

CTA

Clear to auscultation, or CT angiography depending on context.

RRR

Regular rate and rhythm.

NTND

Nontender, nondistended.

CVA tenderness

Costovertebral angle tenderness, often relevant to renal or urinary pathology.

Diagnostic tests

CBC

Complete blood count.

CMP

Comprehensive metabolic panel.

BMP

Basic metabolic panel.

LFTs

Liver function tests or liver chemistries.

Urinalysis.

UPT

Urine pregnancy test.

ECG/EKG

Electrocardiogram.

CXR

Chest X-ray.

Computed tomography.

MRI

Magnetic resonance imaging.

Ultrasound in clinical notes. Can also mean United States in prose.

Troponin

Cardiac biomarker used in evaluation of myocardial injury.

D-dimer

Blood test sometimes used in thromboembolic disease evaluation in appropriate risk contexts.

Lactate

Marker that may support evaluation of shock, sepsis, hypoperfusion, or other metabolic stress.

Medication and dosing terms

By mouth.

Intravenous.

Intramuscular.

SQ/SC

Subcutaneous.

BID

Twice daily.

TID

Three times daily.

QID

Four times daily.

QHS

At bedtime.

QAM

Every morning.

Daily, but many institutions discourage it because it can be misread.

NPO

Nothing by mouth.

OTC

Over the counter.

Contraindication

A reason a medication, test, or treatment should not be used.

Adverse effect

An unwanted or harmful effect of a medication or intervention.

Acronym safety

Acronyms save time only when the reader understands them the same way you do. Some abbreviations are ambiguous across specialties or institutions. In a learning note, clarity wins.

Avoid abbreviations that can mean two different things in the same context.

Spell out high-risk medication instructions.

Use standard disease names when the acronym may be unfamiliar.

Do not use informal shorthand from text messaging.

When in doubt, write the full term.