A.A.D. 自動出院 against-advise dischargeA.D.L. 日常生活活動 activities of daily livingAdm. 入院 admissionB.M. 腸蠕動 bowel movementB.S.A. 體表面積 body surface areaBx. 活體切片 biopsyC.C. 主訴 chief complaintc/o 抱怨 complains ofD.O.D. 死亡日期 date of deathD.N.R. 不急救 do not resuscitateDx 診斷 diagnosisE.D.C. 預產期 expected date of confinementF.H. 家族史 family history Hx. 病史 history I & O 輸入與排出 intake and outputL.O.C. 意識狀況 level of consciousnessM.A.R. 給藥記錄單 medication administration recordM.B.D. 准許出院 may be dischargeO.H.C.A. 到院前心肺功能停止 out of hospital cardiac arrestP.E. 身體檢查 physical examinationP.I. 現在病史 present illnessP.(M.)H. 過去病史 past (medical) historyP.O.H.R. 以健康問題為導向的記錄法 problem-oriented health recordingP.O.M.R. 以醫療問題為導向的記錄法 problem-oriented medical recordingP.O.R. 以問題為導向的記錄法 problem-oriented recordingR 處方、預後 prescription, prognosisR/O 疑似 rule outR.O.M. 全關節運動 range of motionRX 治療 treatmentS.O.R. 以資料為導向的記錄法 source-oriented recordingW.N.L. 正常範圍內 within normal limits
A.A.D. against-advise discharge A.D.L. activities of daily livingAdm. admissionB.M. bowel movementB.S.A. body surface areaBx. biopsyC.C. chief complaintc/o complains ofD.O.D. date of deathD.N.R. do not resuscitateDx diagnosisE.D.C. expected date of confinementF.H. family history
Hx. history I & O intake and outputL.O.C. level of consciousnessM.A.R. medication administration recordM.B.D. may be dischargeO.H.C.A. out of hospital cardiac arrestP.E. physical examinationP.I. present illnessP.(M.)H. past (medical) historyP.O.H.R. problem-oriented health recordingP.O.M.R. problem-oriented medical recordingP.O.R. problem-oriented recordingR prescription, prognosisR/O rule outR.O.M. range of motionRX treatmentS.O.R. source-oriented recordingW.N.L. within normal limits
