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Charting
RCN approved medical terminology
| Question | Answer |
|---|---|
| @ | at |
| a (line over it) | before |
| A.Fib. | atrial fibrillation |
| abd | abdomen |
| AAA | abdominal aoritc aneurysm |
| AB | abortions (termination of pregnancy) |
| ABG | arterial blood gas |
| ADA | American Diabetic Association |
| ad lib | as often as desired, as needed |
| ADL | activities of daily living |
| AK | above the knee |
| AKA | above the knee amputation |
| amb | ambulatory |
| amt | amount |
| ant | anterior |
| ante | before |
| ASAP | as soon as possible |
| b/min | beats per minute |
| BBB | bundle branch block |
| BKA | below knee amputation |
| BP | blood pressure |
| BM | bowel movement |
| BR | bathroom |
| BRP | bathroom priviletes, up to bathroom only |
| Bx | biopsy |
| C1-7 | cervical vertebra |
| C | celsius |
| c (line over it) | with |
| CABG | coronary artery bypass graph |
| cath | catheter |
| C.B.I. | continuous bladder irrigation |
| cm | centimeter |
| C/O or c/o | compains of |
| commode | bedside toilet |
| CPAP | continuous positive airway pressure |
| CPR | cardio-pulmonary resuscitation |
| DOA | dead on arrival |
| dangle | sit at edge of bed, legs over side |
| dc | discontinue |
| decub | decubitis (lying) position |
| defib | defibrillation |
| DNR | do not resuscitate |
| D.O. | Doctor of osteopathy |
| DPT | ditheria, pertussis, tetanus |
| Drsg | dressing |
| Dx | diagnosis |
| EBL | estimated blood loss |
| ENT | ear, nose and throat |
| E.T. tube | endotracheal tube |
| exam | examination |
| Ext. | external |
| F | female |
| F. | Fahrenheit |
| F.U.O | fever of unknown origin |
| FX | fracture |
| ga | gauge |
| GI | gastrointestinal |
| Gm | gram |
| G.N. | graduate nurse |
| Grav (I,II,...ect.) | number of pregnancies, gravida |
| GSW | gun shot wound |
| G-Tube | gastric feeding tube/gastrostomy tube |
| GU | Genitourinary |
| H & P | history and physical |
| Hg | mercury |
| H & H | hemoglobin and hematocrit |
| Hb or Hbg | hemoglobin |
| Hct. | hematocrit |
| Htn | hypertension |
| ht | height |
| Hx | history |
| h, hr. | hour, hours |
| int | internal |
| I & D | incision and drainage |
| I & O | intake and output |
| I.D. | identification and or identify |
| IUD | intra-uterine device |
| irrig | irrgate, irrigation |
| JVD | jugular vein distention |
| kg | kilogram |
| KUB | kidney, ureter, bladder (x-ray) |
| L1-5 | Lumbar vertebrae or nerves |
| Lami | laminectomy |
| LLE | left lower extremity |
| LLQ | lower left quadrant (abdomen) |
| L.P.N. | Licensed Practical Nurse |
| LUE | left upper extremity |
| L | left |
| Lt | left |
| l | liter |
| l/min | liters per min |
| lat | lateral |
| lbs. | pound |
| m | meter |
| M.D. | Medical Doctor |
| MRSA | methicillin resistant staph aureus |
| mcg | microgram |
| MCL | midclavicular line |
| mEq or meq | milliequivalent |
| min | minute |
| misc. | miscellaneous |
| ml | milliliter |
| mm | millimeter |
| mmHg | millimeters of Mercury |
| mo | month |
| mod | moderate |
| NCB | no code blue |
| NH | nursing hom |
| N & V | nausea and vomiting |
| N.K.D.A | no known drug allergies |
| N.P.O | nothing by mouth |
| NSR | normal sinus rhythm |
| N.T | nasotracheal |
| n/a | not applicable |
| NC | nasal cannula |
| neg | negative |
| NG | nasogastric |
| O.J. | orange juice |
| O2 | oxygen |
| PCT | patient care technician |
| P.E. | physical exam |
| P.D. | postural drainage |
| P.I. | present illness |
| POD | post-operative day |
| PRBC | packed red blood cells |
| P.T.A | prior to admission |
| per | by or through |
| PERL | pupils equal and react to light |
| PERLA | pupils equal, react to light accomodation |
| PERRLA | pupils equal, round, reactive to light and accomodation (eyes) |
| PH | past history |
| PND | paroxysmal nocturnal dyspnea |
| PTD | prior to discharge |
| PVC | premature ventricular contraction |
| p | pulse |
| p (line over it) | after |
| pos | positive |
| poss | possible |
| Post | posterior |
| Prep. | preparation, prepare |
| pt. | patient |
| q | every |
| qns | quanity not sufficient |
| qs | quanity sufficient |
| ques | question |
| R | respirations |
| circled R | right |
| RAI | radioactive iodine |
| RLE | right lower extremity |
| R.L.Q. | right lower quandrant (abdomen) |
| R.N. | Registered Nurse |
| R/O | rule out |
| ROM | range of motion |
| ROS | review of systems |
| RTO | return to office |
| RUE | right upper extremity |
| RUQ | right upper quadrant (abdomen) |
| RV | residual volume |
| Reg | regular |
| rbc | red blood cells |
| Rx | recipe (perscription) |
| SaO2 | saturated oxygen |
| S1-5 | sacral vertebra |
| SBO | small bowel obstruction |
| s (line over it) | without |
| S/S or S & S | signs and symptoms |
| sero-sang | sero-sanguinous |
| SIDS | sudden infant death syndrome |
| sl | slight |
| staph or Staph | staphylococcus |
| Surg | surgery |
| Sx | symptoms |
| T1-12 | thoracic vertebra |
| T or Temp (ax,o,r) | temperature (axillary, oral, rectal) |
| T & C | type and cross |
| TKA | total knee arthroplasty |
| TMJ | temporomandibular joint |
| tol | tolerated |
| TPR | termperature, pulse, respiration |
| trach | tracheostomy |
| tx | treatment |
| UE | upper extremity |
| UGI | uppergastrointestinal |
| umb | umbilical/umbilicus |
| US | ultra sound |
| V.O. | verbal order |
| V.S. | vital signs |
| vag | vaginal |
| vent | ventilator |
| Vit | vitamin |
| VRE | vancomycin resistant enterococcus |
| WNL | within normal limits |
| wbc | white blood cell |
| w/c | wheelchair |
| w/o | without |
| wt | weight |
| X | times |
| x-ray | radiology |
| yell | yellow |
| yest | yesterday |
| y/o | years old |
| yr. | year |
| YTD | year to date |