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HUC Transcription

HUC Studies Transcription Process (inclueds abbreviations)

JCAHO "Do not use" list u for unit; iu for international unit; qd for every day; qod for every other day; M.S., MSO4 MGSO4 for magnesium sulfate or morphine sulfate; Trailing zeros or lack of leading zeroes when writing decimals
General rule for preventing errors "When in doubt, write it out."
tech technician
cath catheter
cal calorie
gen general
BRP bathroom privileges
IV Intravenous
US Ultrasound
MRI Magnetic resonance imaging
ad lib ad libitum; freely, as desired
bid bis in die; two times a day
NPO non per os; nothing by mouth
qd quaque die; once a day
qid quarter in die; four times a day
tid ter in die; three times a day
CNA Certified nursing assistant
DO doctor of osteopathy
HUC health unit coordinator
LPN licensed practical nurse
LVN licensed vocational nurse
MD medical doctor
PCT patient care technician
RN registered nurse
ac before meals
asap as soon as possible
as tol as tolerated
bid two times a day
cont continuous
h, hr, hrs hour(s)
hs bedtime, hours of sleep
midnoc midnight
min minute
MN midnight
MR may repeat
nec necessary
pc after meals
prn as necessary
q every
q day every day
qh every hour
qid four times a day
qod every other day
rt routine
stat immediately
tid 3 times a day
amb ambulatory
BR bedrest
BSC bedside commode
CBR complete bedrest
OOB out of bed
ax axillary
BP blood pressure
CMS circulation, motion, sensation
I/O intake/output
NVS neurological vital signs
P Pulse
R Respiration
T Temperature
VS Vital signs
wt weight
HOB Head of bed
lt, L left
rt, R right
AE antiembolism
CBI continuous bladder irrigation
drsg dressing
irrig irrigation
NG Nasogastric
SSE Soap suds enema
st straight
TCDB turn, cough, deep breath
TEDs AE hose
TWE tapwater enema
WMC warm moist compress
cc cubic centimeter
cm centimeter
gtts drops
g gram
gr grain
mEq milliequivalent
ml, mL milliliter
cal calorie
cl clear
DAT Diet as Tolerated
FF force fluids
reg regular
liq liquid
NAS no added salt
NPO nothing by mouth
IM intramuscular
INT intermittent
IVPB intravenous piggyback
po by mouth
subl sublingual
subq subcutaneous
D/RL dextrose lactated Ringers
D5W dextrose 5% water
DW dextrose water
H2O2 Hydrogen Peroxide
LR, RL lactated Ringers
NS Normal Saline
soln solution
TKO to keep open
c (with bar over) with
p (with bar over) after
s (with bar over) without
/ per
@ at