This document provides a list of common clinical shorthand terms used in medical documentation. It includes shorthand for examinations findings (OE, CO), medical history (PH, FH, SH, HPC), routes of medication administration (IV, IM, SC), common conditions (PUO, URTI, CA, CCF), procedures (POP), vital signs (BP), anatomical locations (PR, PV), medication frequencies (OD, BD, TID, QID), relevance indicators (NR, NAD), notation for levels/amounts (-, ±, +, ++, +++, ++++), time periods (5/7, 3/7, 2/52, 1/52, 2/12, 3/12

1. SOME CLINICAL
SHORTHAND
Dr. Dino Sgarabotto
Malattie Infettive e Tropicali
Azienda Ospedaliera di Padova

2. The Most Used Shorthand
• OE On examination
• CO Complaining of
• PH Previous history
• FH Family history
• SH Social history
• HPC History of present complaint
• IV Intravenously
• IM Intramuscularly
• SC Subcutaneously

3. Other common shorthand
• PUO Pyrexia of unknown origin
• URTI Upper respiratory tract infection
• CA Cancer
• CCF Congestive cardiac failure
• POP Plaster of Paris cast
• BP Blood pressure
• PR Per rectum
• PV Per vagina
• OD once daily
• BD or BID Bis in die, twice daily
• TID Ter in die, thrice daily
• QID quarter in die, four times a day
• NR Not relevant
• NAD Nihil ad demonstrandum, 'nothing to show’

4. Plus Notation
- Negative
± Doubtful
+ Mild
++ Moderate
+++ Strong
++++ Very strong

5. Time shorthand
5/7  5 days
3/7  3 days
2/52  2 weeks
1/52  1 week
2/12  2 months
3/12  3 months

6. PN
Percussion
note
VF
Vocal
fremitus
BS
Breath
sounds