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Charting Abbreviatio
Medical Terminology Charting Abbreviations
| Term | Definition |
|---|---|
| ADL | Activities of Daily Living |
| ad lib | as desired |
| AKA | Above Knee Amputation |
| AMA | Against Medical Advice |
| amb | ambulate |
| abd | abdomen |
| bid | twice a day |
| BM | bowel movement |
| BP | blood pressure |
| BR | bedrest |
| Ca+ | calcium |
| CA | Cancer |
| CAT or CT | Computerized axial tomography |
| cath | catheter |
| CBC | Complete Blood Count |
| CCU | Cardiac Care Unit |
| c/o | complains of |
| DOA | Dead On Arrival |
| DC'd | Discontinue (IV or Medication) or discharge (patient) |
| ECG, EKG | Electrocardiogram |
| ED | Emergency Department |
| Fe | iron |
| FX | fracture |
| GI | gastrointestinal |
| GYN | gynecology |
| Hct | hematocrit |
| Hgb | hemoglobin |
| H/o | History of |
| IM | intramuscular |
| I&O | intake and output |
| IV | intravenous |
| K+ | potassium |
| LLE | left lower extremity |
| LOC | level of consciousness |
| LUE | left upper extremity |
| Na | sodium |
| NG tube | nasogastric tube |
| NPO | nothing by mouth |
| NS | normal saline (a common IVF) |
| NWB | non weight bearing |
| OOB | out of bed |
| OR | Operating Room |
| PR | per rectum |
| p | after |
| peds | pediatrics |
| PO | by mouth |
| post-op | after surgery |
| pre-op | before surgery |
| PRN | as needed |
| pt. | patient |
| q | every |
| QID | four times a day |
| RBC | red blood cell |
| RLE | right lower extremity |
| RN | Registered Nurse |
| r/o | rule out |
| ROM | range of motion |
| RUE | right upper extremity |
| RX | prescription |
| SOB | short of breath |
| STAT | immediately |
| SQ | subcutaneous |
| tx | treatment |
| UA | urinalysis |
| URI | upper respiratory infection |
| UTI | urinary tract infection |
| VS | vital signs |
| WBC | white blood cell |
| WNL | within normal limits |
| MVA | motor vehicle accident |
| VSS | vital signs stable |
| ABX | antibiotics |
| DNR | do not resuscitate |
| n/v | nausea and vomiting |
| A, A, & O x 4 | awake, alert and oriented x four |
| NAD | no acute distress |
| GSW | Gun Shot Wound |
| Xfer | Transfer |